MSK Physiotherapy Self Referral Form

"*" indicates required fields

Before you fill out the MSK Physiotherapy form, we need to check you are suitable for our service

You may risk a delay in accessing the right service for your needs, or we may reject your referral if you have not read the below information carefully.

IMPORTANT INFORMATION:

We (LPT MSK Physiotherapy) do NOT provide physiotherapy at the Leicester Royal Infirmary, Leicester General Hospital or Leicester Glenfield Hospital.

To refer yourself for a physiotherapy appointment at Leicester Royal Infirmary, Leicester General Hospital or Leicester Glenfield Hospital please visit the UHL MSK Physiotherapy Service Page .

The sites where we (LPT MSK Physiotherapy) provide appointments are available on our locations page.

If you want to understand more about the 2 NHS MSK Physiotherapy providers in Leicestershire (UHL and LPT) please visit our FAQs page.

This self-referral form is NOT suitable if your main problem is bladder or bowel control, and/or pelvic organ prolapse. Please contact your GP and ask for a referral to the LPT Continence Team or UHL Pelvic Health Physiotherapy Team.

For referrals to other services please visit the list of services available in Leicestershire Partnership NHS Trust. Alternatively some specific service pages are provided below:

Please read and acknowledge the below information before proceeding with this form:

Your GP Practice Name and Address:*

If you are not registered with a GP in Leicester, Leicestershire or Rutland your referral may be rejected.

Your Details

We use this information to identify you and register your referral.

NHS Number:

If you do not know your NHS Number you can look it up here: www.nhs.uk/nhs-services/online-services/find-nhs-number/

Please note; if you do not provide your NHS number this may result in a delay to the processing of your referral. We strongly encourage you to locate your NHS number using the link above before continuing with this form.

Date of birth:*

REMEMBER: We can only accept your referral if you are 16 or older.

Title (Mr/Mrs/Miss...)*

First Name*

Last Name*

Address*

City / County*

Post Code*

REMEMBER: We can only accept your referral if you live or have a registered GP in Leicester, Leicestershire or Rutland.

Do you work for Leicestershire Partnership NHS Trust?*

Job Role / Title*

Directorate & Service / Department*

Do you think your symptoms were, or could have been, caused by your work?*

Current Work Status:*

Have you submitted a self referral form in the last 12 weeks for the same or similar condition/body region?

If you have remembered additional information or would like to update information you previously provided, you do NOT need to complete the full referral form again. Select "Yes" below and you will be given the opportunity to add additional information to your existing referral.

Tell Us About Your Symptoms

This form helps us process your referral accurately and does not replace a clinical assessment with a physiotherapist. Some questions may not seem directly linked to your condition, but they help us build a clearer picture of your health and make sure you can access the right care and support for your needs.

Where is the main area of your body where you have symptoms?*

If you have multiple areas / problems you are seeking treatment for, select the main one here and you can give us more detail later in this form.

Are you PREGNANT or have you given birth in the last 3 months?*

Expected Delivery Date or Date of Birth:*

Have you had an OPERATION that is related to this problem?*

Date of operation:*

What operation did you have?*

include any post operative advice or instructions you have been given and dates of any follow up appointments you have booked

Did your symptoms start after an ACCIDENT or INJURY?*

Date of accident / injury:*

Tell us what happened?*

Have you had a FALL in the last 8 weeks?*

Date of your most recent fall:*

Tell us what happened?*

When did your symptoms begin?*

Do you know what may have caused your symptoms to start?*

For example, a new activity, change at work, illness, stress or anything else you think may be linked to your symptoms.

Please briefly describe your symptoms that you are referring yourself for*

For example, pain, stiffness, pins and needles or tingling, numbness or weakness

Please tell up to 3 things that you cannot do, or find difficult to do, because of this problem*

For example, activities at home, work, caring responsibilities, hobbies or exercise

Have you seen anyone or tried anything to help with this problem?*

For example: What have you tried? Who/What Service did you see? Did it help? How long ago was it?

What help would you like from our physiotherapy service?*

For example, advice and guidance to help manage your pain/condition/return to activity, exercises, a physical assessment, a mobility aid

Communication and Accessibility

We ask about your communication and accessibility needs so we can provide information and deliver care in a format you can access and understand. This helps us make sure you get the right support when you use our services.

Main Contact Number*

We may contact you regarding your appointment or for telephone consultations. Our calls come from a withheld number.

Alternative Telephone Number

Please provide an alternative number to improve our ability to get hold of you

Trying to contact you

After submitting this form, a physiotherapist may contact you if they need to clarify any details.

Therefore to help us get hold of you easily, please let us know if there are any difficulties or limitations to contacting you. i.e. times of day when you are unavailable, or limitations due to poor mobile signal in your area / specific contact numbers.

Consent to SMS and Voicemail?*

We send SMS messages to provide you with details of your booked appointments, or information relating to your care.

If we try and call you we will leave a voicemail to let you know that we called and provide you with details to call us back.

SMS Consent

Voicemail Consent

Enter Email Confirm Email

We use emails to send you information, clinical questionnaires and/or exercises/resources relating to your care. You may get a validation email asking to confirm your details.

Preferred Contact Method*

How would you prefer to receive letters from us?

Post

SMS

App Notification

Do you require an Interpreter?*

Preferred Language?

Alternative Language?

We can find it difficult to locate interpreters for less common languages, therefore if you can communicate in another language, please let us know.

Do you require any reasonable adjustments to help you receive better care or communicate more easily with us?

For example, you may need adjustments related to the care environment (such as lighting, noise levels, or physical access) or you may have a preferred way for us to communicate with you (such as text messages, easy‑read language, or slower-paced conversation).

Please provide further details

Have you previously served in the UK ARMED FORCES?

MSK Physiotherapy Self Referral Form