MSK Physiotherapy Service for the East Riding

Self-Referral Form

To self-refer to physiotherapy you must be aged 18 or over and be currently registered with an East Riding GP and seeking help with an MUSCULOSKELETAL CONDITION

We do not accept referrals for home visits, walking aids, vertigo, breathing, neurological problems, falls assessments, amputees, urinary incontinence or vaginal prolapse, Bell's Palsy or for the general management of Rheumatologicall conditions such as fibromyalgia.

For children aged 5-17 a referral must be done via your East Riding GP on your behalf.

For queries surrounding any of these please contact 01482 247111

Your Information

I am filling the form on behalf of another person

Yes

Forename

Surname

Telephone number

Relationship to patient

Patient Information

Are you registered with an East Riding GP?

Yes

Date of birth

First name

Last name

Address line 1

Address line 2

City

Postcode

Telephone number (landline)

Telephone number (mobile)

Email address

Please confirm your email address

NHS Number (if known)

Do you give consent to share your GP record?

Yes

General health

Firstly can you please tell us a little more about your general health. Have you had any of the following?

New and/or unexplained changes to your bladder and bowel habits, including loss of control or sensation related to the problem you are referring yourself for that hasn't already been assessed by a Healthcare Profession

Yes No

You have chosen 'yes' to the above question. We cannot accept a referral if you have this symptom.

Raised temperature and/or fever, and generally feeling unwell currently that hasn't already been assessed by a Healthcare Profession

Yes No

You have chosen 'yes' to the above question. We cannot accept a referral if you have this symptom.

Onset of symptoms following significant trauma recently that hasn't already been assessed by a Healthcare Profession (e.g. RTA; fall from a height)

Yes No

You have chosen 'yes' to the above question. We cannot accept a referral if you have this symptom.

Recent or unexplained and/or unintentional weight loss that hasn't already been assessed by a Healthcare Profession

Yes No

You have chosen 'yes' to the above question. We cannot accept a referral if you have this symptom.

Do you accept the terms and conditions?

Before participating in any exercise or rehabilitation programme please ensure you have read and understood the following:

These resources are provided by the East Riding MSK Physiotherapy service and are intended for use by patients directed to them from a healthcare professional.
If you follow the advice or exercises on this site without the approval of a healthcare professional, please be aware you do so at your own risk.
Make sure you are wearing comfortable clothes and have enough space to carry out exercises safely.
You should always stop the activity if a new health issue occurs, or an existing condition worsens, and seek advice from a healthcare professional.
The information and resources on this site should not be used for diagnosing or treating a health problem without consultation from a health professional.

Self-Referral Form

Symptom to Check