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 ongoing impact of the coronavirus pandemic, the physiotherapy department is offering both remote (telephone or video) and face to face appointments.
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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
This question requires an answer
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