North Worcestershire Self Referral Form

Service Update

Outpatient MSK physiotherapy appointments cancelled: Do not attend your booked appointment 

We have taken the decision to cancel all ‘routine’ MSK physiotherapy appointments. Your referral has been reviewed by a physiotherapist. Those who are clinically ‘urgent’ will be contacted by phone and a telephone appointment will be arranged. If you are not contacted by phone you have been discharged. 

This decision has been made so we can release our fantastic staff to support the health care teams in the community. The work our team will be doing is vital to save lives, keep critical services running and support patients safely back home.

We absolutely understand the impact that this will have on ‘you’ our patients. Rehabilitation works: it gets people back to work, it promotes independence, it helps athletes win medals, and it supports you to be the best version of yourself. With this in mind please follow us on Twitter @MovetoImprove_  where we will be putting out regular updates on simple steps to help you with your musculoskeletal problem or injury.

CSP resources to support self-managing MSK conditions - in partnerships with NHS England and other agencies

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

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 Bromsgrove or Reddtich?

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 01527 488038. 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.

*Please be aware that the MSK service are utilising telephone and video software to enable the physiotherapist to complete a remote assessment. The telephone number will be withheld so please make sure that your phone allows you to receive incoming calls from withheld numbers. If a video call is required, you will need to download the appropriate software (Webex) to your mobile phone/tablet/laptop/PC and ensure that you have a web camera and microphone. In order to send the invite to the video call, we will require an e-mail address. If a video call is not possible, you will still receive a telephone assessment.

Click here for a BMI Calculator

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.

Complete the form below to self refer

Personal Details

Note: Questions marked by * are mandatory


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