ECO4 NHS REFERRAL

Patients Name*

First NameLast Name

Patients Address & Postcode*

GP Surgery Name, Address and Postcode *

Please fill in the relevant Council

Having carefully considered the patient's medical health conditions, I hereby refer the said patient for the ECO4 Flexibility (ECO4 Flex) policy, as set out by the Department of Business, Energy and Industrial Strategy (BEIS) via route 3: Person suffering from severe or long-term ill-health, as outlined in the ECO4 Flex Administrative Guidance, Route 3 refers to ECO4 legislated conditions listed below:*

A cardiovascular conditionA respiratory disease,Limited mobility,Immunosuppression,

Person suffering from severe or long-term ill-health: I can confirm that the named patient suffers from one of the four health conditions listed above under Route 3 and that their health condition is adversely affected by living in a cold home.

*All referrals must be sent from a valid NHS email address.

General Practitioner (Doctor Name inc. title)*

Email*

example@example.com

Phone number*

GMC Number

Signature*

Date

ECO Improvements Experts Ltd, 84a Hinckley rd Leicester Le3 0rd, Company number: 13607552