Letter Contact

Self-Referral – Contact Us

Thank you for taking the time to complete the D-MAPP self-referral form. Your responses indicate that you may be eligible to take part in the study. Pease complete and submit the form below with your contact details which will be forwarded to a member of the research team at a recruiting centre who will be in touch with you shortly to discuss in more detail. Kind regards, the D-MAPP study team

This page will need a brief privacy statement to cover it for GDPR.

Please enter your patient ID number from your invitation letter *

Title *

Name *

First

Last

Date of Birth *

Phone Number *

Email Address *

Email

Confirm Email

Name of GP surgery *

Name of secondary care site eg. Physiotherapy/Rheumatology clinic (if you have one)

How do you currently manage your condition? *

• At home using advice from my GP
• I see an NHS physiotherapist
• I attend private physiotherapy sessions
• I see a consultant at my local hospital
• Other, please give details (enter below)

If Other, please provide details

How would you usually access the internet? (select all that apply) *

• Computer/laptop via home broadband
• Tablet via home broadband
• Mobile via home broadband
• Mobile data via mobile phone provider
• At work
• Free WiFi away from home (e.g., at a café)
• Other, please provide details

If Other, please provide details

Is your local hospital one of the following (please select) *

• Centre 1
• Centre 2
• None of the above (you will be referred to the research team at Leeds Teaching Hospitals NHS Trust OR Leeds Community Healthcare)

The research team office hours are 9am to 5pm Monday-Friday. Please let us know which days/times are more convenient to speak with a member of the team, although we cannot guarantee someone will be able to call you at this time

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