Physiotherapy Self-Referral Horsham
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1. Important Notice

 
Important Notice
 
If you have recently or suddenly developed:
  • A change in your bladder function
  • Loss of bowel control
  • Altered sensation around your genitals or back passage
  • Loss of sexual function
  • Pins and needles or numbness in both legs
Do Not complete this form and make an Urgent appointment to see your GP or call NHS 111


If you:
  • Have history of cancer within the last 5 years
  • Any unexplained weight loss
  • Are feeling generally unwell/fever
  • Have recently become unsteady on your feet
Do Not continue with this form but make an appointment to discuss this referral with your GP


If you are Under 17 please do Not continue with this form but make an appointment to see your GP