Physiotherapy Self Referral

Physiotherapy Self Referral

Finally, tell us who the referral is for.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone*
NHS Number*
Find your NHS Number here
GP Name*
GP Practice*
Gender*
Ethnicity*
Do you require a language interpreter?*

YesNo
Which language do you require?
Do you have communication or learning difficulties or need reasonable adjustments for your appointments?*

YesNo
Tell us about more about your requirements
Are you off work due to this problem?*

YesNo
Does your pain affect your ability to care for a dependant?*

YesNo

By submitting the self-referral form you are consenting to Cora Health using your data appropriately.

Press Submit below to complete your referral
For more details about how we use your data, please see here

Please call NHS 111 for further advice as these symptoms are signs of infection.

A referral from your GP is required if your symptoms persist.

Unfortunately we are unable to accept a self referral on this occasion.

A direct referral from your GP will be required with additional supporting information to ensure you are seen by the right service.

Back pain in combination with these symptoms could be a sign of something more serious.

These symptoms need checking. You should contact NHS 111 immediately for further assessment. If you have already seen your GP about this issue and they think it is okay for you to have physiotherapy, then we will need a referral directly from them stating that they are aware of these symptoms, but they are not to be worried about.
Should be Empty:

By submitting the self-referral form you are consenting to Cora Health using your data appropriately.