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Carers Referral

Carers Referral

Healthy Lifestyles Carers Referral Form

My Consent

I consent to being referred to the Coventry Healthy Lifestyles Service.

I consent to the release of relevant personal information about myself to the Coventry Healthy Lifestyles Service. I understand this information will be treated as confidential (although it may be used in anonymous form for statistical or research purposes) and that the data controller is my referrer.

I understand that I have (i) the right to change my mind about being referred to the service and to withdraw consent and (ii) right of access to my information.