Physiotherapy self-referral form

Comments

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.

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:

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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