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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If you have recently or suddenly developed
of the following problems, please
complete this form and
call NHS 111
or go to
accident & emergency
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
Inability 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:
None on the above