Physiotherapy Self-referral Form

• You must be registered with an Eastern Cheshire Practice

• Patients below the age of 18 must attend their appointment with a chaperone (children with any development conditions should contact their GP for a referral to specialist paediatric therapy services)

• Patients who require emergency treatment (immediate, serious and life threatening)

• • Please consult NHS 111 or GP urgently if you have recently or suddenly developed difficulties passing urine or controlling bladder/bowels, numbness or tingling around your back passage or genitals, numbness/pins and needles or weakness in both legs

• It is important that you do not self-refer if you have any of the following signs or symptoms without consulting your GP first

• • Changes in your bladder and bowel habits
  • A hot swollen joint
  • Constant severe pain and you are unable to find relief
  • Weakness, pins and needles, loss of feeling
  • Unexpected weight loss

• Please note, the service is NOT permitted to see (Please see your GP)

• • Patients who require emergency treatment (immediate, serious and life threatening)
  • Patients in their own homes (i.e. are housebound in the short or long term)
  • Respiratory conditions
  • Neurological conditions
  • Post amputation (requires a specialist referral)
  • Women’s health problems (except pregnancy related pelvic and/or back pain)
  • Patients who have undergone extensive, complicated surgery, as defined by the operating consultant for an orthopaedic or rheumatological condition which requires specialist intervention

Please also note:

• You are unable to access this service within 6 months if it is for the same condition

• Depending on your condition and needs, you may be offered an initial assessment with advice and guidance. For those requiring further treatment sessions, the average required is usually between 1 to 3 however this will be discussed with you at your initial appointment where you and your physiotherapist will set jointly agreed goals

• Dependent upon the information you enter, you may be eligible to be referred in to the ESCAPE-Pain Programme provided by Everybody Sport and Recreation, as an alternative to physiotherapy. The ESCAPE-Pain Programme provides a number of pain management / advice and support classes over a course of six weeks for patients suffering with pain in the hip and/or knee(s) as a result of osteoarthritis.