MSK Physiotherapy Self-Referral (Anything with Red stars against is mandatory) - Drop down options are for the selection of one option only
Please select who completes this form

Patient Details

(Please check to ensure your email address is correct)
NHS number must be numeric of 10 digits.
Please select yes or not
Please select yes or not
Please select yes or not
Please enter what adjustment(s) you need

Reason for referral

(Please note that you cannot receive treatment for the same problem within 6 months, Alternatively please see your GP for further guidance )
(If yes, please make an appointment with your GP to ensure you receive the right treatment and discontinue with this form )
(If yes, please make an appointment with your GP to ensure you receive the right treatment and discontinue with this form )
(If you are experiencing any of these symptoms please make an appointment with your GP to ensure you receive the right treatment and discontinue with this form )

Musculoskeletal Health Questionnaire (MSK-HQ)

This questionnaire is about your joint, back, neck, bone and muscle symptoms such as aches, pains and/or stiffness. Please focus on the particular health problem(s) for which you sought treatment from this service.
For each question select from the list to indicate which statement best describes you over the last 2 weeks
(This may include sport, exercise and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that is part of your job. )

Selecting your physiotherapy provider of choice

Please select an NHS Commissioned provider

Before you submit, please also check that your email address is correct so that you will receive a copy of your form upon submission.
The provider will be in touch to arrange the appointment date and time

Guidance regarding your data

In accordance to Article 6 (1) (e) within the GDPR Guidance the processing of your data shall be lawful only if and to the extent that you have given consent to the processing of your data for one or more specific purposes, or for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller.

In accordance to Article 9 (2) (h) within the GDPR Guidance the processing of your personal data revealing racial or ethnic origin, political opinions, religious or philosophical beliefs, or trade union membership, and the processing of genetic data, biometric data for the purpose of uniquely identifying a natural person, data concerning health or data concerning a natural person’s sex life or sexual orientation shall be prohibited. – This will statement will not apply whereby processing is necessary for the purposes of preventive or occupational medicine, for the assessment of the working capacity of the employee, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services on the basis of Union or Member State law or pursuant to contract with a health professional and subject to the conditions and safeguards referred to in paragraph 3 of the GDPR Guidance Article 9 (2) (h).

Now please click on the submit button. Upon submission of the form yourself and the provider will receive a copy of this form.