Physiotherapy form

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Please consult NHS 111 or your GP urgently if you have recently or suddenly developed:
•    Difficulty passing urine or controlling bladder/bowels.
•    Numbness or tingling around your back passage or genitals.
•    Numbness, pins and needles or weakness in both legs.

Please discuss with your GP before submitting this referral if you:
•    Are feeling generally unwell/fever
•    Have any unexplained weight loss
•    Have a history of cancer
•    Have recently become unsteady on your feet
 

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Patient information

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Europe/London
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Your address
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If you dont know your NHS number you can find it here 

Next of Kin details

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Please describe your current problem and symptoms below

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