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  • Physiotherapy Self Referral

  • DISCLAIMER

    Please note that we are using Jotform as part of our referral process. Further information can be found on our website. https://www.hrch.nhs.uk/download_file/view/842/377

     

    Please note: Any self-referrals made from outside of Richmond borough will not be considered.

  • Physiotherapy Self Referral

  • Please Read This Before Continuing

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

    • New pain, pins and needles or numbness travelling down both legs
    • New weakness in your legs – this may cause you to stumble or trip, or not be sure where your feet are landing
    • Numbness or tingling around your inner thighs, genitals, back passage or buttocks
    • Any new changes to how your bladder and bowels work e.g. difficulty weeing/starting the flow, weeing more often, not knowing when you need to go to the toilet, weeing or pooing yourself, etc.
    • New changes for men in their ability to achieve an erection or ejaculate or loss of sensation during sexual intercourse
    • New changes for women in their ability to fully feel sensation in the genital or vagina area or climax during sexual intercourse

     

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

    • Have severe pain at night which keeps you awake for hours or stops you from being able to lie flat
    • Have experienced unexplained weight loss
    • Are feeling generally unwell in yourself
    • Have a Fever
    • Have or have had tuberculosis (TB) or a urinary tract infection (UTI – infection of your water works)
    • Have a HIV infection
    • Have a past history of cancer – breast, lung, bowel, prostate, kidney and thyroid
    • Have recently become unsteady on your feet
    • Have experienced night sweats

     

     

    If you have any difficulties with this form please call us on 0208 714 4019

  • Physiotherapy Self-referral

    Your name and contact details
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  • Further Information

  • Your symptoms

  • About Your Symptoms

  • What Affects Your Symptoms

  • If you have a back problem please fill in questions below

    If you have a back problem please fill in questions below(Thinking about the last 2 weeks). If you do not have back pain go to the next section (Existing Medical Conditions)
  • Existing Medical Conditions

  • New Episodes or Changes

  • Other Information

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