SELF REFERRAL TO PHYSIOTHERAPY FOR 
            MUSCULOSKELETAL PROBLEMS, such as

•	Back or neck pain 
•	Recent strain and sprain 
•	Joint or muscle pain
You can refer yourself directly to Physiotherapy without seeing your GP
(Provided you are registered with a local authorising G.P practice).

Referrals for respiratory conditions or women’s/men’s health conditions and for anyone under 16 years of age have to be referred by a GP.

HOW TO ARRANGE A PHYSIOTHERAPY APPOINTMENT:

1.	Complete the attached self-referral form fully - (Please note you can only self-refer for one complaint) 	
2.	Send the referral to the Physiotherapy Booking Centre via post, email or hand delivery to: 

Physiotherapy Booking Centre, Warwick Hospital, Lakin Road, Warwick, CV34 5BW

Email : therapies@swft.nhs.uk   

Please note at some sites your first appointment may be in a class setting 

3.	Approx. five working days after the Physiotherapy Booking Centre has received your referral form please telephone 01926 608068 to book your appointment. (Please note: the booking centre co-ordinates appointments for all South Warwickshire’s NHS Physiotherapy Clinics.)

4.	If we do not hear from you this paper form will be securely destroyed four weeks after the date it was received and the referral will be closed

What can I do to help myself in the meantime?
Research has shown that resting for more than a day or two does not help and may prolong pain and disability. However you may need to modify your activities initially.
Changing your position or activity frequently throughout the day will help prevent and reduce stiffness. 
Over the counter painkillers can be helpful. A pharmacist will be able to advise you on the appropriate tablets.

We are unable to accept referrals over the phone and we cannot BOOK YOU an APPOINTMENT UNTIL WE HAVE RECEIVED YOUR refErral form

When you attend please ensure you wear suitable clothing/footwear to enable your problem area to be assessed appropriately.

							      
SELF REFERRAL FOR PHYSIOTHERAPY 

SELF

I WOULD PREFER TO BE SEEN AT:	
o	WARWICK HOSPITAL 
o	LEAMINGTON REHAB HOSPITAL
o	STRATFORD UPON AVON HOSPITAL 
o	SOUTHAM CLINIC
o	KINETON SURGERY	o	HENLEY MEDICAL CENTRE
o	KENILWORTH CLINIC
o	ELLEN BADGER HOSPITAL
o	ALCESTER PRIMARY CARE CENTRE 
o	BIDFORD ON AVON HEALTH CENTRE	o	MEON MEDICAL CENTRE
o	POOL MEDICAL CENTRE, STUDLEY 
o	HOSPITAL OF ST. CROSS, RUGBY
o	RUGBY GP CLINICS	
NAME:  

ADDRESS: 
DATE OF BIRTH: 
NHS/PID NUMBER: 
TELEPHONE NUMBERS   HOME: 
                                           MOBILE:  
                                            CAN WE LEAVE MESSAGES?  YES/NO	
DID YOUR GP SUGGEST SELF REFERRAL? YES/NO
IF YES, PLEASE STATE WHICH GP

GP PRACTICE: WESTSIDE MEDICAL CENTRE,
HILTON HOUSE, CORPORATION STREET, RUGBY, CV21 2DN
IS AN INTERPRETER REQUIRED?  YES/NO
Sign or verbal language.
Which language?__________________________

	
	
PLEASE COMPLETE ALL THE FOLLOWING INFORMATION:  Only one problem per referral please
Reason for Referral (please give as much relevant information as possible)

If you have back pain and experience any sudden changes to your bladder of bowel habits please seek emergency medical advice

How long have you had this problem for?  0-4 Weeks  /5-16 Weeks  / Greater than 16 Weeks

Is your problem:                 NEW / ONGOING / PREVIOUSLY TREATED BY PHYSIOTHERAPY    (please circle)

Are you off work because of this problem?:              YES / NO    (please circle)
Are you the main carer for someone?                        YES / NO   (please circle)
Do you have any pins and needles associated with this problem?                           YES / NO   (please circle)

If Yes, where are they felt?____________________________________________________________

If you are prescribed medication please list below:

If possible please bring your prescription in with you
	
PLEASE TELEPHONE THE THERAPIES CALL CENTRE ON 01926 608068 TO BOOK YOUR APPOINTMENT 5 WORKING DAYS AFTER DELIVERING THIS FORM TO ONE OF OUR DEPARTMENTS.
If we do not hear from you this paper form will be securely destroyed four weeks after the date it was received and the referral will be closed
PLEASE SEND REFFERAL TO: Email: therapies@swft.nhs.uk      
Post: Therapies Department, Warwick Hospital, Lakin Road, Warwick, CV34 5BW