Physiotherapy Self Referral Form

If you feel that you are suffering from a complaint that could benefit from physiotherapy, you are now able to make a direct referral to the department at Darent Valley Hospital. This offers patients greater choice and faster access to hospital services without the need to visit the GP.

For an appointment please fill out either the:

online self-referral form
or download a paper self referral form and take or post it to: The Physiotherapy Department, Darent Valley Hospital, Dartford, Kent, DA2 8DA or email: dgn-tr.physio@nhs.net

Physiotherapy appointments are at Darent Valley Hospital. We will then contact you with an appointment based on the information you have supplied.

If you have any questions, please contact the Physiotherapy Department on 01322 428588.

IMPORTANT

This self referral option is not available to under-16’s or for neurological, paediatric, respiratory, obstetric or gynaecological problems.

Physiotherapy Self Referral Form

Full Name Required

Date of Birth Required

Address (incl. postcode) Required

Contact Telephone

Email Address Required

Occupation:

Do you require an interpreter?

If yes, which language?

Please give a brief description of why you want a Physiotherapy assessment? Required

How long have you had this complaint? Required

Is the problem? Required

Are the symptoms worsening? Required

Are you able to carry out your normal activities? Required

Are you off work/unable to care for a dependent because of this problem? Required

If you have back pain with leg pain, have you had any difficulties passing or controlling urine? Required

If yes, please give details

Have you suddenly lost any weight without trying? Required

If yes, give details

Have you any other symptoms such as numbness, tingling or muscle weakness? Required

If yes, give details

Please give details of any medication you are taking?

Your GP's Name Required

GP's surgery address: (incl. postcode) Required

I agree to the privacy policy.

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Physiotherapy Self Referral Form

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Physiotherapy Self Referral Form

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Physiotherapy Self Referral Form

What will happen next?

Physiotherapy Self Referral Form

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