Refer Yourself

EXCLUSION CRITERIA……

Please note that HealthshareLondon are unable to treat patients who….
…do not have a suspected musculoskeletal condition.
…are under the age of 16 for physical therapies and interface service.
…are not registered with a GP in the commissioning borough (unless a NCA (non contractual agreement) is in place).
…require inpatient care/day-case services beyond simple procedures and outpatient infusion / injection treatments provided by the community MSK service.
…require NHS England Prescribed Specialist Commissioning Services.
…require home visits.

HELP WITH TRAVEL COSTS……

If you are referred to hospital or other NHS premises for NHS specialist treatment or diagnostic tests by your doctor, dentist or other health professional, you may be able to claim a refund of reasonable travel costs under the Healthcare Travel Costs Scheme (HTCS).  
Visit the NHS UK website to find out who is eligible for the scheme and how to make a claim.
HCT(T) Refund claim form - travel costs to receive NHS treatment.

By filling out this form and submitting it you consent to data being transferred via secure email.  
We would be grateful if you could have your NHS number ready when contacting us or using this self-refer page.

 Please ensure you fill out all mandatory fields marked with an asterisk(*).
When you click the Submit button at the end of the form and it does not appear to work please check that you have completed the required fields.  When submitted successfully you should receive a completion message.

DEMOGRAPHIC INFORMATION

Please select an option

Please state in what capacity you know the patient

Please enter your first name

Please enter your surname

Date of birth*
Please enter your date of birth

**Please use the format DD/MM/YYYY**

Please enter your address

Please enter your address

Please enter your county

Please enter your post code

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Please complete

Please select a number


Please enter a valid email address

If you have provided an email address confirmation of your self-referral will be sent to you when you have successfully submitted the form.
Please check the spam folders within your email if you do not receive a confirmation in your inbox.

Please select an option

Please tick one of the options

Please enter your landline number

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Please enter your mobile number

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Please enter a GP name

Please enter the name of your GP surgery

GP surgery telephone number (if known)

Please select an option

Please enter your NHS number

Please select your height from the dropdown menu

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Please type your ethnicity in the box

Please enter ethnicity


CURRENT DIFFICULTIES
Please enter what part of your body is affected

Please tell us how long you've had this complaint

Please briefly explain why you need physiotherapy

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Please give details

Please give details of your symptoms

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If you require a face to face appointment where would you rather be seen and at what time?
In order for us to plan your care please tick all days and times that are more convenient for you to attend an appointment. The service is open from 8am-7pm Monday to Friday.

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Please select a clinic

For clinic location details please go to Where We Do It

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Under each heading, please tick the ONE box that best describes your health TODAY

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If you click the Submit button and nothing appears to happen please check that you have filled out all the mandatory fields.

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