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Physiotherapy form

The MSK self-referral service will be closing outside of our operational hours. Self-referral will be open and available to complete Monday 8:00 am through to Friday 4:00 pm.  The service will also be closed to self-referrals on weekends and Bank Holidays.

Please consult NHS 111 urgently if you have recently or suddenly developed:

  • Difficulty passing urine or controlling bladder/bowels
  • Numbness or tingling around your back passage or genitals
  • Numbness, pins and needles or weakness in both legs

Please discuss with your GP before submitting this referral if you:

  • Are feeling generally unwell/fever
  • Have any unexplained weight loss
  • Have a history of cancer
  • Have recently become unsteady on your feet

Please contact 111 if you have any ill health that you think is of an urgent nature and for which you think you need medical assistance.

Please note:

Once you have successfully submitted your referral form you will receive a confirmation email, if you have requested one. Please then wait for us to contact you.  We will contact you inviting you to make an appointment as soon as we have availability. Our longest wait is approximately 12 weeks, please be assured we are doing all we can to reduce this time.
 
If you need to contact us, please call 0300 373 0212.

 

I confirm I am 16 years or over (We are unable to accept self-referrals from under 16s, your GP will need to make this referral) Required
Required

Important information

Please consult your NHS 111 or your GP urgently if you have recently or suddenly developed:

  • Difficulty passing urine or controlling bladder/bowels.
  • Numbness or tingling around your back passage or genitals.
  • Numbness, pins and needles or weakness in both legs.

Please discuss with your GP before submitting this referral if you:

  • Are feeling generally unwell/fever
  • Have any unexplained weight loss
  • Have a history of cancer
  • Have recently become unsteady on your feet
I confirm I have read the screening information Required

Patient information

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Are you happy for us to leave a message on this number? Required
Your address Required
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If you dont know your NHS number you can find it here 

Next of Kin details

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Additional needs

Do you have any special requirements (ie. Interpreter/BSL) Required
Are you pregnant? Required

Your referral

Have you recently spoken to another health professional about this problem? Required
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When do you experience pain? Required
Do you wake up at night because of pain? Required
How long have you had this problem? Required
Is the problem getting...? Required
Have you had any tests for this problem? Required
Are you currently absent from work due to this issue? Required
Are your day to day activtities affected by your pain? Required
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