Registration form

Are you a patient or a referrer?*

Patient

Referrer

Check if you’re at risk

Lookup your GP surgery – if you’re a healthcare professional, please search for your patient’s surgery

Surgery Practice*

This field is hidden when viewing the form

Contract area(optional)

Enter your readings

The readings may have been provided when you received the referral. If you don’t have them, please contact your GP surgery to ask for them.

Select the blood test results you are providing*

HbA1c reading*

You can type this to one decimal place, such as 42.0

Date of HbA1c reading*

Your HbA1c blood test must have been taken in the last year.

FPG reading*

You can type this to one decimal place, such as 5.5

Date of FPG reading*

Your FPG blood test must have been taken in the last year.

Title*

First name*

Please enter your first name

Last name*

Please enter your last name

NHS number*

An NHS number is a 10-digit number, like 485 777 3456. Please add you NHS number removing any spaces or dashes.

Date of birth*

You must be age 18 or older to register for the programme.

Gender*

Please select your gender

Ethnicity

Please select your ethnicity from the dropdown below.

Do you have a visual impairment?*

Do you have a hearing impairment?*

Do you require a BSL interpreter?*

If required, what is your preferred method of contact?*

Email address*

Please type a valid email address that includes a single ‘@’

How would you like us to call you?*

Please select all the ways you’d like us to call you

Telephone

Mobile

Telephone number*

This must be a UK phone number that’s 11 digits long

Mobile number*

This must be a UK mobile number that’s 11 digits long, starting with ’07’

Please select which numbers above we can leave you a voicemail on*

Address*

Address Line 1 Address Line 2 City County Postcode

Do you speak english?*

What is your first language?*

Register for the NHS Diabetes Prevention Programme

Step 1 of 5 – Referral details

Lookup your GP surgery – if you’re a healthcare professional, please search for your patient’s surgery

Enter your readings