Referral Form

After submitting your request, please read carefully the green box that will pop up. If you wish to view a copy of your submitted form you must click where requested within 5 minutes of submitting the form. Shortly after your submission, you will receive an email confirming the receipt of the form by REMAP Gloucestershire.

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 green MUST be filled in - grey fields are optional and red fields are for Remap use only. You must fill out a valid email address - if you do not know the email of the referrer, then please use your own email.

If you are filling out the form for yourself, please complete the Referrer and Client details with your name and address (cut and paste) and enter 'Self' or 'Client' in the 'Referrers Role' field.

Please DO NOT use all capital letters as this causes problems with spam filters when the form is transferred - thank you.

	Gloucestershire Panel Referral Form CONFIDENTIAL	Case No:
		Date for Review:
Referred on:		Engineer:

Client Name:		Referred by:
Address:		Address:
Telephone no:		Referrer's Role:
Age:		Telephone no:
		email:

Disability:
Description of the problem and service requested:

Description 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 attending:

Who owns the equipment to be modified (if client, enter 'client'):
Have all commercial options been investigated:		Yes	No

		Status:
If you would like to attach a photo to help REMAP access your requirements please select a JPEG file from your computer and add a brief description of the photo. Leave these two fields blank if you do not wish to add a photo. Description of photo...

		Tick this box if you made the client aware of Remap's policy on Data Protection. Click here to read the policy. Make sure you click in the I'm not a robot box and wait for the green tick before submitting your request. You may be asked some additional questions. Please wait...