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