Important Notice
 
 
If you are PREGNANT or UNDER 17 years of age please contact your surgery for a GP appointment. Please DO NOT complete this form as we cannot accept your referral on this occasion.
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IMPORTANT: If you have recently or suddenly developed ANY of the following problems, please DO NOT complete this form and call NHS 111 or go to accident & emergency for URGENT medical attention.
  • Numbness/loss of feeling around buttocks, back passage or genitals
  • Inability/increasing difficulty to empty your bladder
  • Loss of sensation when you pass urine
  • Not knowing when your bladder is full or empty
  • Loss of sensation when passing a bowel motion
  • ‚ÄčInability to stop a bowel movement or leaking
  • Change in ability to achieve an erection or ejaculate
  • Loss of sensation of genitals during sexual intercourse

To continue with the self-referral form you are required to confirm you are not affected by ANY of the above: