Who is making the referral request?
Referred By:
Macmillan GP Self Referral
Support Group (Please State)
Health or Social Care Professional (Please state)
Other (Please State)
Referrer Contact No ………………………………………….
Client’s details
Name
Address
Preferred Contact number / Date of birth
Employment status / Employed / Self Employed / Unemployed / Other (Please State)
Is client off sick? / Yes / No / At risk of sickness absence
Date sickness absence began / ____ /____/____ / If fit note issued, dates / from___/___/___ to ___/___/___
GP surgery details
Surgery name and address (stamp)
Medical status
Cancer Patient Cancer Carer
NHS No. :
Location of cancer:
Newly Diagnosed Awaiting Treatment Undergoing Treatment Cancer Controlled
Signature: ______Print Name:______
Once this form has been completed send by fax or post to:
The Fit for Work Team
Voluntary Action LeicesterShire
9 Newarke Street, Leicester, LE1 5SN
Fax: 0116 285 1716 Tel: 0116 285 1710
Copyright © 2012 The Fit For Work Team.
All Rights Reserved.
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