Self-referral is not appropriate for patients with the following symptoms.
If you have experienced any of the following DO NOT FILL IN THIS FORM, please consult your GP for a referral. For symptoms 1 and 2 seek urgent medical advice.
1. Unexplained bladder or bowel problems
2. Numbness or tingling around back passage or genitals
3. Pins and needles or numbness in both arms or both legs
4. Pain at night that persists despite changing your position
5. Fever or night sweats
6. Unexplained weight loss
7. Unsteady on feet
8. On current treatment for Cancer
Instructions
- You must be 18 years old or over to refer to this service.
- You should be seeking help for a musculoskeletal (bone, joint or muscle) problem such as back pain, arthritis or a sprain.
- Referral following orthopaedic surgery must be from the Orthopaedic team.
- You must have a GP registered within North Cumbria area to refer yourself through to this service.
- If you have multiple area of concern please complete separate self-referral forms for each.
- Please note that self-referral is not appropriate for patients with any of the 8 symptoms on the top of your referral form.
Please complete the form as fully as possible; the more information that we are given, the easier it is for us to direct people to the most appropriate service. Once completed email to: ncm-tr.ncic-imsk-referrals@nhs.net or see below for postal address.