Referral Form

After submitting your request you will receive an email confirming the receipt of the form by REMAP Gloucestershire. You must fill out a valid email address, otherwise you will not receive confirmation that your request has been accepted - if you do not know the email of the referrer, then please use an email address of someone who you can ask wether your request has been accepted.

Only use this form if you intend to submit your request electronically - if you wish to fill out the form manually and send it by post, please use the blank form and post the completed form to the name and address on the form.

The personal data on this form will only be used to assist in the work that may be carried out and will never be disclosed to anyone outside Remap Gloucestershire. Please make sure the client is aware of this information. More information can be seen by reading the Information for Client Leaflet.

The fields coloured MUST be filled in - grey fields are optional and solid red fields are for Remap use only. The red glow surrounds will disappear ( ) once filled with valid data. Please DO NOT use all capital letters.

Gloucestershire Panel

Referral Form

CONFIDENTIAL

Case No:

Date for Review:

Referred on:

Engineer:

Referrer's Information
Name:
Address:
Telephone:	Email:	Role:

Client's Information
Name:
Address:
Telephone:	Age:	Gender:


Disability

Description of the problem and service requested

Summary:

Any other information


It is REMAP Gloucestershire's policy that a third party must be present on the initial visit, and any subsequent visits as deemed appropriate.
Who is the third party:

Who owns the equipment to be modified:

Have all commercial options been investigated:	Yes	No

If you would like to attach some photos to help REMAP assess your requirements please select any number of JPEG file from your computer and add a caption for the photos. If you add more than one photo all photos will have the same caption. Use the caption to refer to the photo(s) in the 'service requested' field above. Leave these two fields blank if you do not wish to add any photos. Please note the system will NOT accept any other files. Caption for photo(s)... characters left.

Tick this box if you made every effort to make the client aware of Remap's policy on Data Protection. Click here to read the policy.


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