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The Docs NHS GP Surgery in Manchester

Physiotherapy self referral

Physiotherapy Self Referral Form

Patient Details

Referral Date:

NHS Number:

First Name: *

Surname: *

Email Address: *

Date of Birth: *

Please use this format: DD/MM/YYYY

Contact Number: *

Address: *

Postcode: *

Main Spoken Language: *

Do you need an interpreter? *

Yes

(please note it is not trust policy to use family or friends)

About Your Problem

Please give details of your problem: *

We will only see you for one problem. If you have more than one problem please put it on a separate referral.

How long have you had this problem? *

Have you previously had physiotherapy for this problem within the last 6 months?

Yes

Have you had any investigations or surgery relating to this problem? *

Yes

Please give details:

About Your Current Symptoms

Have you recently had any episodes of loss of control with your bowel or bladder which the GP is unaware of? *

Yes

Please give details: *

Book an urgent appointment to see your GP before continuing with this referral.

Is your sleep pattern significantly disrupted by this problem? *

Yes

Please give details: *

Are you off work or restricted in your work duties because of this problem? *

Yes

Please give details: *

Is this problem affecting your ability to care for someone? *

Yes

Please give details: *

Confirmation

I can confirm that the above details I have provided are correct to the best of my knowledge

Signed: *

If you are human, leave this field blank.

55-59 Bloom Street
Manchester
M1 3LY

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