Important Notice
If you are PREGNANT or UNDER 16 years of age, please make a GP appointment. Please DO NOT complete this form as we will be unable to accept your referral.
Due to the Coronavirus pandemic, the physiotherapy department is offering a remote TELEPHONE or VIDEO assessment service as the first contact. If your self-referral is suitable for this service, you can expect to be contacted within 10 working days. This may vary due to short notice changes in services. 
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: *