OUTPATIENT AND WOMEN’S HEALTH PHYSIOTHERAPY REFERRAL FORM
Note: This referral form is for Outpatient Women’s Health and Musculoskeletal Physiotherapy only. For details regarding how to refer to
other Physiotherapy or the Musculoskeletal Centre and FAQs please visit our website (www.smcs.nhs.uk)
Please see page 2 for further details regarding other therapy services available and a guide on which service is most appropriate
Please complete this form in full as incomplete/illegible forms will be returned which will delay the referral
PATIENT DETAILS
Title:
M
F
Forename(s):
Surname(s):
NHS Number:
D.O.B:
Address (incl. postcode):
Daytime contact number:
(We may contact the patient from a withheld number to discuss this referral)
Alternative contact number:
We may contact patients from a withheld number so it is important for patients to be aware of this so they are less likely to ignore the call. We will not leave voice
messages in line with information governance policy
Is an Interpreter required:
NO
YES If yes, which language:
Does the patient have a learning disability?
ETHNICITY
It is important to complete this section. Recording of ethnicity is important in order to tackle health inequalities and understand the medical needs of minority
communities
White British
Any other mixed background
Black/Black British Caribbean
White Irish
Chinese
Black or Black British African
Any other White
Asian or Asian British Indian
Any other Black groups
Mixed: White/Black Caribbean
Asian or Asian British Bangladeshi
Any other ethnic group
Mixed: White & Black African
Asian or Asian British Pakistani
Declined to state ethnicity
Mixed: White & Asian
Any other Asian background
REFERRER DETAILS
Date of Referral:
This information allows us to ensure our
referral process is carried out in a timely
manner
Contact Number:
Address:
GP/Consultant/Referrer Name:
Fax Number:
It is essential that we have the correct address of the referrer in order to facilitate communication regarding the referral
GP Practice:
NHS.net email address:
The NHS.net email address (e.g. generic Practice NHS net address)
of the referrer allows us to communicate securely and easily with
the referrer
We are commissioned to see patients only under the care of a
Sutton or Merton GP. Referrals for patients who are not
registered with a GP in Sutton or Merton cannot be accepted
TRIAGE
PLEASE INDICATE BODY PART(S):
SPINAL
UPPER LIMB
LOWER LIMB
OTHER (Please indicate)
This information is important in order to ensure patients are triaged onto an appropriate clinical pathway and we can monitor the clinical
needs of our patients as a whole
REFERRAL REASON/DIAGNOSIS AND RELEVANT MEDICAL HISTORY OR ATTACH EMIS REPORT
(If post-operative: Operation details including a copy of op notes, post-op instructions and date of surgery are ESSENTIAL)
(If post-fracture: Date of fracture and mobilising instructions are ESSENTIAL)
The appropriate course of treatment for post-operative and post-fracture patients cannot be carried out without this information)
PLEASE TICK THE BOXES THAT BEST DESCRIBES THIS PATIENT:
Completion of this section is essential in order to triage patients onto an appropriate clinical pathway and ensure that they are seen in a
timely manner
U30
NON-SPINAL SURGERY OR A FRACTURE IN THE LAST 12 WEEKS?
OPY/WH REFERRAL FORM VERSION 3 FEB 2014
U
U
U
U
U
U
SPINAL SURGERY OR A FRACTURE IN THE LAST 12 WEEKS?
INJURY/TRAUMA IN THE LAST 6 WEEKS
ACUTELY OFF WORK (LESS THAN 6 WEEKS) DUE TO THIS PROBLEM
PATIENT IS A REGISTERED CARER AND THE SYMPTOMS ARE AFFECTING THEIR CARING CAPABILITY
CORTICOSTEROID INJECTION IN THE LAST 2 WEEKS
DIAGNOSIS BY PAIN CLINIC OF CHRONIC REGIONAL PAIN SYNROME (CRPS)
P
PREGNANCY RELATED PAIN AND ≥34/40 WH(P)BACK
PREGNANCY RELATED BACK PAIN
WHCP
INCONTINENCE
OR PELVIC ORGAN PROLAPSE WH(P)SPD PREGNANCY RELATED PELVIC PAIN
_____/40 EDD: _____/_____/_____ {INTERPRETER=1:1}
PTA
REQUIRES EQUIPMENT PROVISION ONLY (SPLINT, STICK OR CRUTCHES)
R
NONE OF THE ABOVE
DOES THE PATIENT REQUIRE AN APPOINTMENT WITHIN:
5 WORKING DAYS?
YES NO
IF YES PLEASE INDICATE REASON:
OTHER SPECIFIC TIME (E.G POST-SURGERY??
YES
NO
IF YES PLEASE STATE TIMEFRAME:
PLEASE NOTE: PATIENTS WHO HAVE HAD UNSUCCESSFUL PHYSIOTHERAPY FOR THE SAME CONDITION WITH NO SIGNIFICANT CHANGE IN THEIR
CIRCUMSTANCES ARE UNLIKELY TO BENEFIT FROM RE-REFERRAL. PLEASE CONSIDER REFERRAL TO PAIN CLINIC, PAIN MANAGEMENT (COPE) OR
ORTHOPAEDICS
A significant number of referrals to physiotherapy are for patients who have had unsuccessful treatment in the past and are unlikely to
benefit from further physiotherapy. Referral to another service is likely to be more appropriate
Please return this referral form to the Sutton and Merton Administration Centre:
Email: rmh-tr.smcsadmin@nhs.net Fax: 020 3458 5888 Telephone: 0845 567 2000
Address: SMCS Administration Team, PO Box 70926, London, SW19 9FS
OUTPATIENT AND WOMEN’S HEALTH PHYSIOTHERAPY REFERRAL FORM GUIDANCE
The Outpatient Physiotherapy Service provides high-quality evidence-based musculoskeletal physiotherapy assessment and treatment in a
clinic-based setting to patients registered with Sutton and Merton GPs. Health promotion, self-management and full participation in
treatment are all fundamental components of the Outpatient Physiotherapy Service.
Objectives of the service
1. To provide an efficient assessment and advice service to patients with a musculoskeletal problem.
2. To advise on self-management of long-term conditions and degenerative diseases such as osteoarthritis, and to work within
care pathways to maximise patients’ independence.
3. To progress rehabilitation of patients following orthopaedic surgery or intervention, e.g. joint replacement, spinal surgery, and
post-fracture.
Inclusion criteria

16 years and over

Registered with a Sutton or Merton GP
Exclusion criteria

Housebound patients

Where serious pathology is suspected

Post-operative patients who do not have a copy of their operation notes
Before making a referral please consider whether an alternative therapy service is more appropriate. Hover over the services below to
follow the link to our website:
Patient Need
Multidisciplinary rehabilitation and care in the community for people with neurological
conditions
Short-term rehabilitation for patients in bedded units prior to discharge back to their own
home


Service Required

Community Neurotherapy Team

Community Rehabilitation Team
Patients who are 65 years or over who have had a fall, have a fear of falling or are at risk of 
falling
Falls Prevention Service
Non-urgent diagnosis of musculoskeletal disorders where serious pathology is not suspected
and appropriate primary care interventions have been undertaken
Musculoskeletal Centre
Assessment and rehabilitation of a physical / medical condition which affects functional
ability
Older People’s Assessment and
Rehabilitation Service (OPARS)
Podiatric Surgery
Operable conditions of the feet such as hallux valgus, hallux rigidus, osteoarthritis, soft-tissue
lesions (neuroma, cysts, ganglion, etc), toe deformities or metatarsalgia
Prevention of unnecessary patient admission
OPY/WH REFERRAL FORM VERSION 3 FEB 2014

Rapid Response Team