Self-refer into our physio service

For those living in Evesham, Droitwich, Pershore, Malvern, Tenbury, Worcester and Upton. Please click here if you live in Bromsgrove or Redditch

Before you complete the self-referral form

  • Have you been using the advice and tips on the self-help sections for around 8 weeks? 
  • Are you still feeling pain or discomfort?
  • Are you registered with a GP practice in Evesham, Droitwich, Pershore, 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 who may sometimes decide that a telephone assessment is appropriate for your condition you are referring for. 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.

You can call 0300 790 0599 Monday - Friday: 8.30am - 16:00 to check the progress of your referral or to cancel an appointment that you no longer require. *Please note that you cannot self-refer by calling this number, please instead complete the self – referral form below.

Physiotherapy Triage


‘Cauda Equina Syndrome’, although rare, can cause a permanent change to your bladder and/or bowel function, or foot strength. Cauda equina syndrome is a condition which occurs when the nerves at the base of the spinal cord become squeezed in the spinal canal. This can happen quite suddenly or gradually. It can cause pain in the lower back and/or legs, numbness or weakness in one or both legs, in the buttocks or between the legs (the ‘saddle region’). It can also cause problems with bladder or bowel control and sexual function.

IF you are suffering with low back pain and if you have any changes regarding the following since your pain started;

  • Bladder or bowel function (i.e., Increasing difficulty when you try to urinate, increasing difficulty when you try to stop or control your flow of urine, loss of sensation when you pass urine, leaking urine or recent need to use pads, inabilityof knowing when your bladder is either full or empty, inability to stop bowel movement or leaking, loss of sensation when you pass a bowel motion)
  • Loss of sensation / tingling around genitals, back passage, buttocks or inner thighs
  • Erectile or ejaculation problems or loss of sensation in genitals during sexual intercourse
  • Loss of sensation/ tingling or numbness in both legs • Weakness in foot (i.e. floppy foot or inability to lift front of foot when walking)

If YES call NHS 111 or go to A+E IMMEDIATELY


IF you are suffering with constant pain and if you have any of the following;

  • History of Cancer
  • Unexplained weight loss
  • Feeling generally unwell/ fever/ lack of appetite
  • Relentless night pain that cannot be relieved by changing position in bed

Please contact with your GP as soon as possible to discuss if other investigations are required rather than self- referring to physiotherapy.

Referral form

Personal Details

Note: Questions marked by * are mandatory


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