Hillbrow Health and Wellbeing (WAH) Self-Referral Form

Hillbrow Health & Wellbeing Self Referral

Complete the fields below
Lewes District and Eastbourne Borough Council Areas

This service provides access to safe, supported physical activity for people with health conditions and offers referral clinics, specialist exercise classes and health improvement programmes.

Please complete the fields below. Email the completed form to referral@waveactive.org or return by post to: Wave Active Health Team, Wave Active, Downs Leisure Centre, Sutton Road, Seaford, E Sussex, BN25 4QW
Your Details
Full Name

TitleFirst NameLast Name
Date of birth

DayMonthYear
Date
Contact Number
Please enter a valid phone number.Format: 00000 000000.
Email Address
example@example.com
NHS Number
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Your GP Surgery:
Preferred Contact Method:

Hillbrow Health & Wellbeing Self Referral