Physiotherapy Self-Assessment Form

If your doctor has asked you to fill in a form, you can download and print it from the link below:

Self-Referral Physiotherapy Form

Please follow the instructions in the guide on the second page. Please do not return the form to the surgery. 

  • Hand deliver your form to reception at Vicarage Lane Health Centre, 10 Vicarage Lane, E15 4ES
  • Post the form to PBS, Vicarage Lane Health Centre, 10 Vicarage Lane E15 4ES
  • Email to: newham.pbs@nhs.net