Solent MSK Physiotherapy Self-Referral Form

Please read the statements below and tick to confirm:*
• I am aged 16 or over
• I am registered with a GP in either Southampton or Portsmouth City

Important information below, please read before you start to complete this Self Referral form.

Please consult your GP or NHS 111 urgently if you have recently or suddenly developed:

• Difficulty passing urine or controlling bladder/bowels.

• Numbness or tingling around your back passage or genitals.

• Numbness, pins and needles or weakness in both legs.

Please discuss with your GP before submitting this referral if you:

• Are feeling generally unwell/fever.

• Have any unexplained weight loss.

• Have a history of cancer.

• Have recently become unsteady on your feet.

Patient Demographics
Forename* Surname* Gender* Date of birth* Email Address* Postcode* SouthamptonPortsmouth Patients Address* Contact Tel N°* NHS N° GP Practice Name Are you pregnant? YesNo If yes,please state how many weeks pregnant Do you have any special requirements? (i.e. Interpreter/BSL) YesNo If yes to special requirements, please supply further information