Tell us about yourself

About You

First Name(S) *

Last Name(s) *

Date Of Birth *

Your address *

Your Postcode *

Email Address *

Mobile/telephone number *

NHS number (if known)

Preferred method of contact *

Airmid app Phone Email Letter

Main language spoken

Disclaimer

Before using our physiotherapy self-referral platform, please read the following statements:

• The physiotherapy self-referral system is not an emergency service. If you have a medical emergency, call 999 or 111.
• Decisions made about advice and treatment are done so based on the information you have provided and do not constitute a medical diagnosis.
• You have a responsibility to thoroughly read the information provided to you before attempting any exercise and/ or lifestyle change.
• Your data and personal information are safe and may be shared with your GP practice but not be shared with any third parties.
• I confirm that the contact details I have provided are accurate and up to date and can be used by the by the physiotherapy service to communicate with me.

I have read and accept the above information. *

Once you have completed this form, please head back to our How to refer yourself to physiotherapy page to complete the next important step in the self-referral process.