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Telehealth Referral Form
Telehealth Referral Form
*Please note this Referral Form is for the use of health professionals only
Telehealth Referral Form
Title
*
Forename
*
Surname
*
Known as
*
Gender
*
Date of birth
*
NHS Number
*
Personal email
*
Primary telephone
*
Secondary telephone
*
Address
*
Postcode
*
Prescriber name
*
Prescriber team
*
Prescriber email and contact phone number
Access / Additional information
*
*Disclaimer: Please note for patients that have osteoporosis, a pacemaker, artificial lungs, portable ECG monitor, or any such medical device should NOT use the Biometric scales. These scales send a pulse through the body that may effect a patient who has any of these.
*
The patient has been provided with an information leaflet which describes the service and details how Hywel Dda University Health Board collects, uses, retains and discloses personal information. The patient understands that their data will be used for the purpose of monitoring their readings and understanding their longer term health.
*Please tick box to confirm you have read and understand the disclaimer.