Croí Referral Form

Please complete this referral form and a member of the Croí Health Team will get back to you. This form helps us to understand how we can help you.

Who is this form for? This form is for anyone with questions or concerns related to heart conditions or stroke, or risk factors for heart conditions or stroke, including blood pressure and cholesterol.

Who can complete this form? Members of the public and healthcare providers are welcome to use this form to contact the Croí Health Team. Healthcare providers, please ensure you have your patient’s permission before completing this form on their behalf.

Once submitted, you will be connected with the Croí Connects helpline. Our Cardiovascular Nurse Specialist will review your form and make contact with you. Our nurse may signpost you to a range of different resources, including online talks, exercise classes and videos, and support for healthy eating and exercise.

Who is on the Croí Health Team? Our Health Team includes nurses, a dietitian, an exercise and physical activity specialist, an occupational therapist and a health psychologist.

Please complete this form to connect with the Croí Health Team.

Patient Contact Details

DD slash MM slash YYYY
Address(Required)

DD slash MM slash YYYY
Consent(Required)
Is this a self-referral? (If 'Yes', move on to the Medical Details section)(Required)
Is this a self-referral? (If 'Yes', move on to the Medical Details section)

GPs/Organisation's Address
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