Musculoskeletal Outpatient Physiotherapy Referral Form
Fax: 0300 303 9964 Email: [email protected]
Note: Provide services work to NHS Connecting for Health policies and can only send responses including
patient identifiable details (PID) to email addresses that are approved by them. If you are not using an
approved email address this may limit the response we can make by email.
Date of Referral:
NHS Number: <NHS number>
Patient Details
Forename: <Patient name>
Surname: <Patient name>
Address and Postcode: <Patient address>
Date of Birth: <Date of birth>
Gender: <Gender (configurable)>
Home Telephone Number: <Patient contact details>
Mobile Telephone: <Patient contact details>
Preferred Contact Number:
Ethnicity: <Ethnicity>
Interpreter required
Yes
Please state language
No
Please indicate which site he patient is able to attend:
Braintree
Halstead
Maldon
Chelmsford
Shortest Wait (any
(any site)
site)
Reason for Referral
Please provide as much information as possible in relation to the nature and duration of symptoms
If this is a referral for back pain ensure STarT Back questionnaire completed*
Onset of Symptoms
0 – 2 Weeks
Work Status
Has the patient recently become unfit for work due to this
problem?
2- 8 Weeks
Yes
> 8 Weeks – Detail date of onset below
Date:
No
Unemployed/
Retired
Is the patient unable to care for a dependent due to their present
condition?
Yes
No
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Has the patient been seen by Physiotherapy
for this problem within the last 6 months?
Yes
No
Is this a chronic condition that the patient has had for over 6 months?
Yes
No
If yes to either of the above please explain why further physiotherapy is deemed
appropriate:..............................................................................................................................................................
.....................................................................................................................................
Recent investigations/interventions + Summary of findings
Steroid injection
X – Ray - Include results where
possible
MRI - Include results where
possible
Blood test
Other
Date………………
CT
Medical History (Incl. Current Medication)
Transport
Transport Required?
Yes
Referrer Details (complete if not patient’s GP)
No
Tick if patient’s GP
Print Name: <Your name>
Job Role:
Organisation\Service: <Current organisation details>
Telephone: <Current organisation details>
Please send your completed referral form:
BY FAX: 03003039964
BY EMAIL: [email protected]
Please complete the form as thoroughly as possible to ensure your patient is triaged appropriately.
Referrals with an insufficient data set will be returned. Patients with referrals for back pain without a STarT
Back questionnaire will be returned in accordance with our service specification.
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