Physiotherapy self-referral form

Email
This field is for validation purposes and should be left unchanged.
Confidential Application for Physiotherapy Treatment

Please read the Health and Rehabilitation Centre Policy Notice.

Patient details:
Patient's name*
Please let us know the patient's title and name.
First name Surname
Patient's Date of Birth*
Please enter the patient's date of birthday in a DD/MM/YYYY format.

Day
Month
Year
Patient's address*
Please enter the patient's address.

Address line 1 Address line 2 Town County Post code
Patient's mobile number*
Please enter the patient's mobile number.
Patient's Email*
Please enter and confirm the patient's email address.
Enter email Confirm email
Preferred contact method*
Doctor's Surgery*
Please tell us the name of the patient's Doctor's Surgery.
Surgery address:*
Please tell us the address of the patient's Doctor Surgery.

Address line 1 Address line 2 Town County
Emergency contact name*
First Last
Emergency contact's mobile number*
Please enter the mobile number of the patient's emergency contact.
If you have any allergies, please list them

Initial Safety Check:
Have you recently experienced any of the following?
Please tick any that apply
- Loss of bladder/bowel control
- Severe unexplained pain at night
- Unexplained weight loss / history of cancer
- Sudden weakness in face, arm, or leg
- Difficulty speaking or vision changes
- Severe dizziness or fainting
- Falls in last 12 moths
- Fever or signs of infection
- Abdominal aortic aneurysm
Please supply details for any of the above*

Medical Information:
Do you have any of the following?*
Tick all that apply
- Heart condition
- Breathing problems
- Neurological condition (e.g. stroke, Parkinson’s)
- Diabetes
- Arthritis or joint problems
- Recent surgery or fracture
- Balance problems or falls
- Other
If you selected 'other' please describe*
Please list any medication allergies:

Support and Accessibility:
Do you need any support to attend or take part?
- Carer support
- Language or communication support
- Wheelchair access
- Help with mobility
- Other
If you selected help with mobility, please provide details*
If you selected Other, please describe*

Appointments and Cancellations:
What is your appointment preference?*
- Student clinic
- Physiotherapist
- Self-Employed Physiotherapist
If you cannot attend your appointment, please let us know as soon as possible. We ask for at least 24 hour’s notice for cancellations otherwise charging fee may apply and affect future bookings

Consent:
Consent*
I confirm that the information provided in this form is accurate and complete to the best of my knowledge.*
Consent*
I consent to assessment and treatment by the Health and Rehabilitation Centre Physiotherapy Service.*
Consent*
I understand that, as a student-led clinic, my assessment and treatment may be undertaken by physiotherapy students under the supervision of a qualified physiotherapist.*
Consent*
I confirm that if any of my medical details or medication change, I will inform the physiotherapist or student physiotherapist*
Consent*
I understand that a clinical record will be created and maintained as part of my care.*
Consent*
I acknowledge that I have been informed of the Health and Rehabilitation Centre Privacy Notice and understand how my personal information will be processed.*
Data Protection Statement The Health and Rehabilitation Centre processes and stores personal and special category health information in accordance with the UK General Data Protection Regulation (UK GDPR), the Data Protection Act 2018, and applicable professional and healthcare record-keeping requirements. Your information will be used for assessment, treatment and ongoing healthcare provision; appointment administration and service management; clinical governance, audit, quality assurance and educational purposes where appropriate; and compliance with legal, regulatory and professional obligations. Your information will be held securely and accessed only by authorised personnel involved in your care, supervision, administration or quality assurance activities. Further information about how your personal information is collected, used, stored, retained and shared, together with your rights under data protection legislation, can be found in the Health and Rehabilitation Centre Privacy Notice.

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Physiotherapy self-referral form

Patient details:

Initial Safety Check:

Presenting Problem:

Medical Information:

Support and Accessibility:

Appointments and Cancellations:

Consent: