Health Coach Referral

Do you smoke? Have you thought about trying to quit? Have you thought about how much alcohol you drink? Would you like to increase your exercise? Or perhaps you are thinking of eating more healthily?

Complete the form below to speak to our new Health Coach.

Security

Please be aware that communication by email, by its very nature is not 100% secure and by communicating with Saundersfoot Medical Centre, you consent to us monitoring and reading any such correspondence.

Health Coach Referral Form

This check will take just a few minutes. Please answer each question as honestly as you can by clicking in the correct boxes.

Do you smoke? *

Are you interested in increasing your activity? *

Would you like to talk to someone about your diet? *

How often do you drink alcohol? *

How many drinks do you drink on a typical day when drinking? *

How often have you had 4 or more drinks, if female, or 6 or more if male, on a single occasion in the last year? *

Name: *

First

Last

Date of Birth: *

Post Code: *

GP Surgery *

Phone Number: *

Email *

When is the best time to contact you? *

Referral Type *

Saundersfoot Medical Centre
Tel: 01834 815115

Kilgetty Branch Surgery
Tel: 01834 812600

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Saundersfoot Medical Centre
Tel: 01834 815115

Kilgetty Branch Surgery
Tel: 01834 812600