Physiotherapy Self-Referral Form for Pregnant & Postnatal WomenJemima Hughes2022-11-30T10:48:45+00:00
If you would like to fill in the form by hand, click here to download a printable version.
Physiotherapy Referral Form for Pregnant and Postnatal Women
Please only use this tool of you are currently pregnant, have been pregnant or given birth within the last year.
Please use this tool if you want to have physiotherapy treatment because you are leaking from your bladder or back passage, you feel a bulge or heaviness down below, you experience pelvic - or back pain, you have had a C-section or you feel there is a gap between your tummy muscles.
The questions in this form will help us to make sure we provide the best level of care for you. We will keep your answers confidential and they will not be linked to your medical records.
More information can be found by reading our privacy notice.