GP Referral Programme

Health Declaration

Please fill out the following form
in order to participate in our GP Referral Programme. Please note that this 12-week programme is £109 payable in advance.

First Name

Last Name

Date of birth

Phone *

Email *

Please list any medication you are on for the referred condition or any others that could affect your wellbeing on the course:

Lifestyle

Do you smoke?

Do you drink Alcohol?

Do your exercise for more than 30 mins per week?

Do you eat 5 portions of fruit or veg a day?

Do you ever have:

Fear of Falling

Feeling unstable

History of falling

Low bone density

Initials

Consent

I consent to the above information being passed on to the exercise specialist and agree to disclose and further information regarding my health which may affect my ability to exercise. I agree to returning this form on day 1 to participate on the course and reading Atrium fitness terms and conditions, general rules before participating on the course. I am committed and have purchased the 12 week with reception

I accept the terms and conditions

I accept the terms and conditrions of the GP referral scheme

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company.