Physiotherapy self-referral for hip pain

Your responses to this questionnaire will be processed by an approved NHS data server. Your responses will be emailed to the Lewisham Hospital physiotherapy NHS mailbox and this information will be uploaded to your NHS records. We will delete any personal information stored locally, but may use anonymised data for service evaluation and improvement purposes. By completing this questionnaire you consent to us using your data in this way.

Please note that the self-referral pathway is currently only for patients who are registered with the Sydenham Green Group Practice, Woolstone Medical Centre, Vale Medical Centre, and Wells Park Practice. Please do not attempt to complete the referral if you are registered with another GP as your referral will be rejected.

This self referral form is for hip pain only. If you require treatment for more than one problem, please complete additional questionnaires relevant to each area separately or consider speaking to a healthcare professional prior to referring.