Physiotherapy Self Referral

Please Read This Before Continuing

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

• Difficulty passing urine or controlling bladder/bowels

• Numbness or tingling around the 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 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’

 

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