Self-referral | Bolton Hospice

About You

Name

Address

Date of Birth

How did you hear about the Wellbeing Hub?

Contact details

Home number

Mobile number

What is your preferred contact number?

Home

Mobile

Do you give us permission to leave a message?

Email

Next of kin

Name

Contact number

Medical Conditions

What medical conditions do you have?

What services would you like to access at the Wellbeing Hub?

Advice from specialist nurses

Socialising & peer support

Creative therapy

Complementary therapy

Condition specific group, Memory Café, Pulmonary Fibrosis Support Group, etc.

Wellbeing sessions

Other…

What problems would you like help with?

GP Name & Contact Details

The personal information you have provided to Bolton Hospice will be processed in accordance with current UK data protection legislation and our privacy policy which is available to view at www.boltonhospice.org.uk/privacy-policy or upon request.

The main purpose for which we process your personal information is to administer your self referral but for further information please see our privacy policy. Your information will be held securely.