Physiotherapy Self Referral Form

Physiotherapy self-referral is a system which allows you to refer yourself directly to a physiotherapist without having to see a doctor first.

Please click here for more information about whether this is right for you and how it works before filling in the form.

Physiotherapy Self Referral Form

Patient Details

Please use this format: DD/MM/YYYY
(please note it is not trust policy to use family or friends)

About Your Problem

We will only see you for one problem. If you have more than one problem please put it on a separate referral.

About Your Current Symptoms

Book an urgent appointment to see your GP before continuing with this referral.

Confirmation

FOR GP USE ONLY

(If question 4 has been answered please attach corresponding documents. Please also ensure NHS number and referral date is complete)
Self-referral community physiotherapy form: please forward by secure email to physiotherapy attaching
— this patient completed self-referral form
— summary patient problem list and medication
— details of any investigations or surgery for the condition (see question 4)