Refer Yourself

EXCLUSION CRITERIA……

Please note that HealthshareCentralLondon 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.

First name *

Please enter your first name
Date of birth *

Please enter your date of birth
Address 1 *

Please enter your address
County

Please enter your county
Contact number *

Please enter your contact number
GP name *

Please enter a GP name
Please give a brief description of why you need physiotherapy *

Please tell us why you need physiotherapy
Is the problem... *


Please select an option
Are you able to carry out your normal activities? *


Please select an option
Are you having difficulties sleeping? *


Please select an option
Have you had any difficulties passing or controlling urine? *


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Have you suddenly lost any weight without trying? *


Please select an option
Have you had any other symptoms such as numbness, tingling, or muscle weakness? *


Please select an option
We will inform your GP of your self-referral. Please tick this box only if you do NOT wish your GP to be informed.

Tick if you do not want your GP to be informed of your self-referral.



Surname *

Please enter your surname
Email Address

Please enter a valid email address
Address 2

Please enter your address
Post code *

Please enter your post code
NHS Number

Please enter your NHS number
GP surgery *

Please enter the name of your GP surgery
How long have you had this complaint? *

Please tell us how long you've had this complaint
Are the symptoms worsening? *


Please select an option
Are you off work with this problem? *


Please select an option
For back pain referral, do you currently have leg pain?


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Please contact your GP immediately



Please give details *

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