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Worcestershire Health and Care NHS Trust
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web banner - MSK self referral form

Before you complete the self-referral form

  • Are you still feeling pain or discomfort?
  • Are you registered with a GP practice in Evesham, Droitwich, Peshore, Malvern, Tenbury, Worcester and Upton?


If you have answered
yes to all the above then you should complete the below form, providing as much information as possible.

Please enter the following information and press submit once. Once submitted you will receive a read receipt and email confirmation. Your Information will now be prioritised by a physiotherapist. Please wait 7 working days and then call 0300 790 0599 to book your assessment. You may have to wait some weeks for the assessment depending on how your referral has been classified and current numbers of patients waiting to see the physiotherapist. Opening times for calling: Monday - Friday: 8.30am - 12:30pm. This will ensure your referral is on our system. If we do not hear from you by 3 weeks from today you will be discharged from our service. 

*Please note that you cannot self-refer by calling this number, please instead complete the self – referral form below.

Click here for more help and advice to improve your condition. 

If your condition improves whilst waiting to be contacted and you no longer require an appointment please let us know by calling: 0300 790 0599 between 8.30 to 12.30

Please follow us on Twitter @MovetoImprove_

 

Our clinics: 

  • Evesham- Evesham Community Hospital, Waterside, Evesham WR11 1JT
  • Pershore- Pershore Community Hospital, Queen Elizabeth House, Queen Elizabeth Drive, Pershore, Worcs, WR10 1PS
  • Malvern- Malvern Community Hospital, 185 Worcester Road, Malvern, Worcestershire, WR14 1EX
  • Tenbury- Tenbury Community Hospital, Worcester Road, Tenbury Wells, Worcs, WR15 8AP
  • Upton- Upton GP Surgery, Tunnel Hill, Upton-upon-Severn, Worcestershire WR8 0QL
  • Worcester- Crowngate Physiotherapy, 48-49 Friary Walk, CrownGate Shopping Centre, Worcester,WR1 3LE
  • Droitwich - Droitwich Medical Centre, Ombersley Street East, Droitwich Spa, WR9 8RD
  • Inkberrow - Grey Gable GP Surgery, Inkberrow Worcs WR7 4BW

  • Bredon Hill - GP Surgery, Main Road, Bredon, Tewkesbury GL20 7QN

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Please note before self-referring that possible pain; discomfort and bruising can occur during and after assessment by a physiotherapist although an attempt is made to minimise these as able. Please can you wear appropriate loose clothing if possible, including bringing some shorts if required and available and note that you may be asked to remove some items of clothing with your consent. This is to help with the assessment process. 


Please note that if a patient does not attend their appointment and does not make contact within two weeks of the missed appointment they will automatically be discharged. Also if a patient does not attend two occasions during a course of treatment they will be automatically discharged after the second occurrence. 

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Self-referral form
Patient contact details
Define your condition
The Keele StarT back screening tool
(ONLY complete if this is a back referral)
Thinking about the last 2 weeks select your responses to the following questions:
you may be referred to the Functional Restoration Services if deemed appropriate once your referral has been triaged: https://personalhealth.healthcare-rm.com/personal-health-services/#restoration