Please make sure that your physiotherapy self referral form is completed in
full. Then return the self referral form to the physiotherapy department:
Physiotherapy Department
Gilbert Hitchcock House
Kimbolton Road
Bedford
MK40 2NU
If you have any concerns regarding your physiotherapy referral please
call us on 01234 792088.
If you need an interpreter or would like a chaperone you may wish to
bring somebody with you. Alternatively, if you need us to provide you
with a chaperone or an interpreter please contact the department in
advance on 01234 792088.
Any concerns or complaints
We are always trying to improve our service and we do welcome any suggestions or
comments. We would also like to have the opportunity to answer any concerns or
complaints you may have. If you do have any comments or complaints please speak to
the physiotherapist treating you in the first instance.
If you need further assistance, the Patient Advice and Liaison Service (PALS) will be
able to help. The PALS Office has a 24 hour confidential answer phone or they can
be contacted by letter at the following address:
PALS Office
Bedford Hospital NHS Trust
South Wing
Kempston Road
Bedford, MK42 9DJ
Self Referral to
Physiotherapy
We have now introduced
a way for you to see a
physiotherapist without
having to see your GP
first.
Just fill out the form
inside this leaflet in full
and send it to the
address supplied.
If you have any concerns,
you can always see your
GP first and then be
referred for
physiotherapy in the
normal way.
What problems can we help with?
The physiotherapy team can help patients to improve, maintain or
restore their physical function after an injury, operation or during
and after pregnancy. Physiotherapy can also be beneficial for
problems associated with continence control or pelvic pain.
Some of the muscle and joint problems that physiotherapy can
help with include: back pain, neck pain, shoulder pain, hip pain,
knee pain and ankle pain
PHYSIOTHERAPY SELF REFERRAL FORM
(for Patient/Family use only. This is not a substitute for clinical referral forms).
** denotes a mandatory field: referral may be rejected if not fully completed.
** Name:
** Date of Birth:
(not available if
under 16 years)
** Address:
** Telephone Nos:
** GP Name:
** Postcode:
** GP Surgery:
Date:
** Please give a brief description of why you need physiotherapy
How would you prefer to have physiotherapy?
Telephone advice
□
Face to face appointment
□
How long have you had this problem?
Are the symptoms worsening?
Yes
Are you able to carry out your normal activities?
Yes
Have you had physiotherapy for this problem before?
Yes
Are you off work/unable to care for a dependent because of
Yes
this problem?
Are you having difficulty sleeping because of this problem?
Yes
If you have back pain, have you had any difficulties
controlling your urine?
Yes
Have you suddenly lost weight without trying?
Yes
Have you had any symptoms such as numbness, tingling
or muscle weakness?
Yes
Do you require an interpreter?
Yes
□
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□
□
□
□
□
□
□
No
No
No
No
No
No
No
No
No
□
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□
□
□
□
□
□
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If yes, how long ago
□
N/A
N/A
□
If yes, please see your GP first
If yes, please see your GP first
If yes, please see your GP first
If yes, what language
How do I refer myself to physiotherapy? Just follow these three easy steps.
1
Please complete the
referral form above with as
much information as you can
to give us a clear
understanding of your
condition. Any query regarding
your referral please ring 01234
792088.
2
Please return
the completed referral form to:
Physiotherapy Department, Gilbert
Hitchcock House
Kimbolton Road, Bedford
MK40 2NU
Or FAX to: 01234 409232
Or email bhn-
[email protected]
3
Once a physiotherapist has
looked at your form you will be
sent a letter for you to book your
appointment. When you ring to
make an appointment please
make sure that this is a date and
time that you will be able to
make.