Prior to completing this self-referral form please be advised that:
• We can only accept self-referrals from patients 16 years or older
• Referrals are for one condition only, you cannot refer for multiple conditions at a time
In some instances the physiotherapist that you are seen by may contact your GP practice to ask for relevant information about your medical history.
If you do not want your GP practice to be contacted in this way please make this very clear to the person you see at your appointment.