MSK Physiotherapy Self Referral Form

Self Referral Form

MSK physiotherapy first contact form

"*" indicates required fields

Step 1 of 5

Prior to completing this MSK Physiotherapy form, please confirm the below:

Do you work for Leicestershire Partnership NHS Trust?*

For LPT Staff please use the Staff Referral Form (you will need to login to StaffNet)

Do you require an appointment at Leicester Royal Infirmary, Leicester General or Leicester Glenfield Hospital (UHL)?*

We do NOT provide physiotherapy appointments at the University Hospitals of Leicester (UHL) sites (Leicester Royal Infirmary, Leicester General Hospital, or Glenfield Hospital).

Please visit the UHL MSK Physiotherapy Service Page to access their referral form

For a list of the sites we offer appointments, please visit our locations page.

Exclusion Criteria:*

Are you...

under 16 years old?

referring yourself for a respiratory or neurological condition (i.e. Stroke / Parkinson's Disease)?

requiring treatment in your own home / residence?

None of the above

You do NOT currently meet our above referral criteria for MSK Physiotherapy to self refer to our service.

For referrals to other services please refer to their relevant pages below or visit the list of services available in Leicestershire Partnership NHS Trust

Adult Community Therapy

Adult Community Integrated Neurological and Stroke Service (CINNS)

Adult Falls Prevention Service

Pulmonary and Heart Failure Rehabilitation

Children's Physiotherapy Service

Have you attempted any of the self help resources available on our website?*

We would advise you try out the resources available BEFORE referring to our service.

These are available on our resources page , and contain a range of leaflets, videos and information to help you manage your symptoms.

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:*

Name*

Name

Prefix First Last

Address*

Address

Address Line 1 Address Line 2 County Post Code

GP name and address:*

You should be registered with a GP in Leicester, Leicestershire or Rutland in order for us to accept your self-referral.

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.

Preferred Contact Number*

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

Alternative Contact Number

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

After submitting this form, a physiotherapist may need to 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.

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 Link

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 British ARMED FORCES?*

Protected Characteristics

We ask these questions to help ensure people are treated fairly and to improve our services for all communities. This information helps us understand health inequalities and make care better for everyone. Your answers are confidential, and you can choose ‘prefer not to say’ if you don’t want to answer.

Do you have any Diagnosed or Perceived Disabilities?

How does your disability affect you?

Please share how your disability affects you, particularly in relation to attending or receiving outpatient physiotherapy appointments.

How can we support you?

If you haven’t already done so, please tell us what adjustments or support would help us deliver the best possible care and improve your experience with our service.

What best describes your Ethnicity?

What best describes your Religious Affiliation?

What best describes your Marital Status?

Next Steps

By submitting this form, I understand that:

I may receive a telephone call within the next few days but only if a physiotherapist needs to clarify any of the information I have provided.
After my form has been reviewed, I am likely to receive exercises or self‑management resources to help me start managing my condition. I will also be given information about how to book an appointment if this is required.
I will only be contacted directly to arrange an appointment if it is clinically required.
If my condition or symptoms are not suitable for this service, or if they would be better managed by another service, I will be sent a letter explaining what to do next.
Written communication will normally be provided as a letter. This will be sent via email or SMS link where consent and contact details are available, or by post if not.
If you have not received written communication (or a call) outlining what to do next, within 7 days of submitting your form, please contact us on 0300 300 0046 or email llr.msktherapy@nhs.net.

Acknowledgment

I accept

Name and relationship of the person completing this form (if not the patient):

MSK physiotherapy first contact form

Prior to completing this MSK Physiotherapy form, please confirm the below:

Your Details

Understanding Your Condition or Symptoms

Communication and Accessibility

Protected Characteristics

Next Steps

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