Please complete this secure Phase 4 cardiac rehab referral form with the key details needed to assess suitability for supported exercise. If you require a general referral form you can access the link here:
Secure Medical Self-Referral & General Exercise Referral Form
This form is for people looking for supported exercise after a cardiac event, cardiac procedure, NHS cardiac rehabilitation, or diagnosis of a heart condition.
Clinicians do not need to rewrite full medical notes. Please complete the key safety questions and attach a cardiac rehab discharge summary, clinic letter, medication list, exercise test result, or other relevant document where available.
Information submitted through this form is handled through the Wix platform, which provides enterprise-grade website security and encrypted data handling when configured appropriately. Where applicable, Wix also supports HIPAA-compliant workflows when the correct privacy settings, protected health information settings, permissions, and Business Associate Agreement requirements are in place.
https://www.wix.com/website-security
This form is not for urgent medical problems. If you have chest pain, severe breathlessness, fainting, stroke symptoms, or feel seriously unwell, please call 999.