Physiotherapy self-referral form

To self-refer to the NHS North Tyneside Integrated Musculoskeletal Service (NTIMS) for physiotherapy, please complete the form below.

All fields are required

Your personal details

Full name Date of birth

Day Month Year / /

Postcode The NHS in your area provides early access to specialist physiotherapy for back pain and sciatica.

What is the main reason for your referral today?

I have back pain and/or sciatica

I have a problem with another bone, muscle or joint

Please select your GP from the list below

Your contact details

Email address Mobile number