Falls Prevention Program Enquiry Form

Falls Prevention Program Enquiry Form
Thank you for enquiring about our Falls Prevention Program. This program aims to deliver increased freedom, confidence, strength, balance and safety.
- The next course starts September
- Each course runs for 8 weeks.
- Each 8 week course costs £160
- The course is run in small group format
- The course will run in a safe space, off the gym floor
- The program is only available at David Lloyd Warrington currently
Please complete the form and once submitted our Patient are Team will be in touch.
Id like to bookI'd like more information pleaseI'd like to book a free taster session
Is the course for you or someone else?*

For meFor someone else
Name of person completing the form*

First NameLast Name
Name of the person looking to join the course

First NameLast Name
Please tell us their relationship to you
Preferred Contact Email*
example@example.com
Preferred contact number
How would you prefer to be contacted?

PhoneEmailI don't mind
Please tell us the main reason for interest in the course*

Help post fallPrevention of fallConfidenceMobilityFlexibilityStrengthImprovement in daily task abilityOther
Please use this space to give us any further details of challenges and goals that may be relevant to the person looking to join our program
Have you had a fall in the past 6 months?

YesNo
If you have any further questions please detail them here:
Once submitted our Patient Care team will be in touch within 48 hours.

Please note spaces are limited.
Should be Empty: