Physiotherapy Service Self Referral Form - Health in Wales 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your full name and title at the top of the form. Ensure you use BLOCK CAPITALS for clarity.
3. Fill in your address, postcode, date of birth, and sex. This information is crucial for processing your referral.
4. Provide your contact telephone numbers and indicate if messages can be left on each line (home, work, mobile).
5. Describe your symptoms briefly and specify how long you have been experiencing them. Include details about how the issue started.
6. Indicate the frequency and intensity of your pain, as well as any factors that worsen or alleviate it.
7. Answer questions regarding previous treatments, tests, and any relevant medical history. Be thorough to avoid delays.
8. Complete the general health section by ticking 'YES' or 'NO' for various conditions and medications you may be taking.
9. Finally, sign and date the form before submitting it to ensure all sections are completed accurately.

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