Get in Touch

I am...*

Name

Name of individual you are referring

First line address*

Postcode*

Contact telephone number

Email address

Date of birth

Gender*

Ethnicity

What areas would you like support with? (select all that apply)

Which Birmingham Service do you wish to apply for?

Do you/does the patient speak English?

GP details

You must be registered with a GP to be eligible for support.

How did you hear about Health Exchange?

Referral Source (if referring someone else)

GP

Community Organisation

Other

Call us on 0800 158 35 35 or fill out the form below