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 ongoing impact of the coronavirus pandemic, the physiotherapy department is offering both remote (telephone or video) and face to face appointments.
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: *