NHS physiotherapy self-referral

This page is for NHS patients who would like to self-refer for physiotherapy treatment with Ascenti. Please read all of the below information before starting the form to check that you are eligible to self-refer.

Once you have completed the below form, your referral will be reviewed by our team who will then contact you to discuss the next steps of your rehabilitation journey.

Important notice
While self-referral to physiotherapy is appropriate for the majority of people, there are some exceptions where we would advise you to seek alternative medical assessment first.
Please do not complete this referral and call NHS 111 or immediately attend your local A&E if you have recently or suddenly developed, with the onset of low back pain and/or leg pain:

A change in your bladder function or bowel control
Altered sensation around your genitals or back passage
Loss of sexual function

Please do not complete this referral and make an appointment with your GP if you have any of the following (your GP will need to complete a referral on your behalf):

History of cancer, or being actively treated for cancer
Unexplained weight loss
Pain and/or altered sensation in both arms and/or both legs
Have become unsteady on your feet
You've noticed changes in your vision, speech or swallowing
Have become feverish or are feeling generally unwell

Please note: This referral option is not available if your referral is regarding a neurological, paediatric, respiratory, obstetric or gynaecological condition. This referral route is also not available if you have a fracture or have had surgery to the affected area in the past six months or have a suspected infection. Should you have any of these other conditions, please contact your GP.
To use this service you must be registered with a GP practice in one of the NHS areas listed on the dropdown below, and be 16 years of age or older. If you need treatment for more two body parts, please do not complete this form and instead contact your GP for a direct referral.
NHS number
You will need to know your NHS number to complete this form. If you are unsure what your NHS number is, please click here.
Form display
If you have any issues viewing or completing the questions while using a mobile, please try using a computer or laptop instead. Alternatively you can ring our NHS Admin Team on 0330 678 0851