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District Direct Referral Form

DISTRICT DIRECT

For the attention of

Patient details

Male/female
Interpreter required

Referral details

Does the patient require a going home pack?
Does the patient require a referral to Careline or Lily?
Is the patient able to return home?

Referrer details

Is the person homeless?

Excluder details

As the person is homeless, please complete excluder details where possible:

Privacy Notice

The Council has a duty to process and store your personal information safely and securely in line with data protection legislation, which here means the General Data Protection Regulations (Regulation (EC) 2016/679 which is in force from 25 May 2018) (GDPR) and any national implementing laws, regulations and secondary legislation, as amended or updated from time to time, in the UK and then any successor legislation to the GDPR.

View the privacy notice in full

Declaration

Please read this declaration carefully before you press submit.

  • I certify to the best of my knowledge and belief, the information supplied by me on this form is accurate.
  • I understand the personal information collected on this form will be used by the Borough Council of King's Lynn and West Norfolk to process my request, and deliver the service.
  • I understand that the information provided on this form is subject to the provisions of the General Data Protection Regulations (Regulation (EC) 2016/679 which is in force from 25 May 2018) (GDPR).

You can find out more detailed information about our Privacy Policy, on our privacy notice page.


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