Dr Sivakumar & Dr Gude’s Surgery

01942 878711

Adult MSK Self-Referral Form

Please click below to download the form. Once completed, this can be handed directly to MSK on the second floor of Boston House Entrance A.

You can refer yourself for physiotherapy without visiting your GP first by filling in the form above.

Please note: If you have any of the following, please see your GP before referring yourself:

  • Changes in your bladder and bowel habits.
  • A hot swollen joint.
  • Constant severe pain and you are unable to find relief.
  • Weakness, pins and needles, loss of feeling.
  • History of cancer

Fill in all the boxes on the second page and either post, email or hand deliver that page to one of the Physiotherapy Departments listed below

Physiotherapy departments

  • Boston House, Wigan Health Centre, Frog Lane, Wigan, WN6 7LB, TEL: (01942) 482260 [email protected]
  • Platt Bridge Health Centre, Rivington Ave, Platt Bridge, Wigan, WN2 5NG, TEL: (01942) 482403 [email protected]

Please note these email addresses are for referrals only. Please do not use the email to contact department for any other purpose. Unless an email is encrypted the security of that email cannot be guaranteed.

Who is eligible?

Anyone over 16 years old who has pain or discomfort in their muscles, joints or ligaments. You must be able to attend one of the physio outpatient departments; this form is not for patients who require a home visit.

What happens once the form has been handed in?

Your referral form will be looked at by a Physiotherapist and they will decide whether they can help with your condition.

When the physio department are in a position to offer you an appointment, they will contact you.

Whilst awaiting your appointment, helpful advice can be found at:



If your condition changes after submitting your self-referral, please contact us for advice.