Self-Referral Form

Prior to completing this self-referral form please be advised that:

  • We can only accept self-referrals from patients (16 years or older) living within the Plymouth catchment area, who are registered with a Plymouth GP.
  • You must be seeking help with a Musculoskeletal problem, such as neck or back pain or soft tissue or joint problems such as strains and sprains.Further guidance can be found on our web page https://www.plymouthhospitals.nhs.uk/physio-self-referral
  • It is important you do not self-refer if you have any of the following conditions without consulting your GP
    Unexplained weight loss, unexplained bladder or bowel problems, history of cancer, night pain, fever or night sweats, unsteady on feet or pins & needles/numbness in both arms or in both legs.

Can I refer for multiple problems?
We request that you refer for just one condition per referral.  This is to keep waiting times down and improve the quality of your care.

Once a physiotherapist has completed care for this condition you may then refer again for something else if necessary.

Physio Self-referral

Note: Questions marked by * are mandatory

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