Service available in:

Self-referral form for physiotherapy

To refer yourself for physiotherapy please fill in the form online below. Please note: If you have any of the following, please see your GP before referring yourself:

  • Changes in your bladder and bowel habits.
  • A hot swollen joint.
  • Constant severe pain and you are unable to find relief.
  • Weakness, pins and needles, loss of feeling.
  • History of cancer

We cannot accept a self referral if you are under 16 years of age. You will need to be referred by your GP. 

Required
Required
Gender Required
Date of birth Required
Address Required
Required
Required
Address of your GP practice
Required
Can we leave you messages on your voicemail / answer-machine?
Do you consider yourself to have a disability? Required
Do you require an interpreter? Required
Required
Required
Required
Have you had NHS physiotherapy for this problem in the last 12 months?
Is your problem affecting you at work?

Declaration

As part of providing you with direct care, the Trust may have to share your information with other partner organisations. To find out more information about this, please refer to our Privacy Policy.

By submitting this form, I am giving permission for the Trust to use my data and agree to the Trust contacting me using the details given above.. I understand that the Trust will:

  • securely store the information relating to my referral (and subsequent care, where applicable) in paper and/or electronic format
  • keep the records for as long as required in the Records Management Code of Practice for Health and Social Care 2016 (or for longer if it is appropriate)
  • confidentially destroy records when necessary
Required