OAADS Referral Form
OAADS REFERRAL FORM
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Please try to complete all sections and discuss with us if you have problems with this.

Email: referral@kingwood.org.uk or leave a message on 01235 359388; we will respond within five working days of your contact.

NB The ‘supporter’ is the person requesting assessment on your behalf (if applicable).

By submitting this form you are agreeing to your details being held on a confidential database.


In order for us to process your referral:

1.We will need to share relevant confidential information with the clinic.

2.We may also need to contact & share information with those who may be involved in your care & well-being.

3.By signing this form you or your supporter are agreeing to the above. All personal information will be treated as confidential and subject to the Data Protection Act 1998, by all services. You may request access to the personal information held about you.
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About you
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*First Name
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*Surname
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NHS Number if known
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*Date of birth
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*Address
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*Postcode
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*Phone number
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Email address

(By letting us know your Email Address you are giving us consent to email you)

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*Next of kin
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Your ethnic origin
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*First language
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Your religion/belief
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*Your gender





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If you have selected 'other'. Please let us know here what gender title you prefer
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*Name of your GP: Dr
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*Phone number
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*Practice address
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*Postode
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