Pulmonary rehabilitation online self-referral form

What is Pulmonary Rehabilitation?

Pulmonary Rehabilitation is a supervised exercise and education programme for people with a diagnosed long-term breathing condition. It aims to help you feel less breathless, improve fitness, and feel more confident doing everyday activities

Please read before you submit

• This form takes about 5 to 10 minutes to complete.
• If you are very unwell, have severe chest pain, or are struggling to breathe at rest, call 999 or contact NHS 111 / your GP urgently.
• You must be aged 18 or over and have a diagnosed respiratory condition to be considered.
• Submitting this form does not book an appointment immediately. We will review your answers and may contact you for more information.
• Completing this form does not guarantee acceptance. Eligibility depends on NHS Pulmonary Rehabilitation guidance and local service criteria.
• We can only accept self-referrals if you are registered with a GP practice in:
  • Middlesbrough, Redcar and Cleveland, or
  • Hambleton and Richmondshire
    If you live outside these areas, please contact your GP for advice.
• You need to be willing and able to attend an initial face-to-face assessment and, if suitable, take part in PR twice per week for 6 to 7 weeks.
• We do not accept self-referrals if you have attended PR in the last 12 months, unless you have been admitted to hospital overnight due to your breathing since then.

If you are completing this form on someone else’s behalf, please use their details.

Need help completing the form?

James Cook University Hospital (Middlesbrough) and Redcar Primary Care Hospital (Redcar)

• Telephone: 01642 944607 (please leave a message if busy or outside office hours)
• Email: [email protected]

Friarage Hospital (Northallerton) and The Friary Community Hospital (Richmond)

• Telephone: 01642 854218 (please leave a message if busy or outside office hours)
• Email: [email protected]

Self-referral form