Physiotherapy Self-Referral Mid-Sussex
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1. Important Notice

 
Important Notice
 


If you have recently or suddenly developed the following with the onset of your lower back pain and / or leg pain:
 
  • A change in your bladder function or bowel control.
  • Altered sensation around your genitals or back passage.
  • Loss of sexual function​.

Do not complete this form and make an Urgent appointment to see your GP or call NHS 111.


If you any of the following:

 
  • Any unexplained weight loss.
  • Are feeling generally unwell / feverish.
  • Have recently become unsteady on your feet.

Do not continue with this form but make an appointment with your GP to discuss this referral.


Please do not continue with this form and instead make an appointment to see your GP if you are:

 
  • Under 16.
  • Unable to attend the Outpatient Department. If you believe you need domiciliary physio (physiotherapy at home).
  • Seeking treatment for Neurological or respiratory disorders.