Self-referral form for Orthotics

Exclusion Criteria:
  • New conditions or new prescriptions (different item required): A new referral would be needed from a Knowsley or St Helens GP.
  • Domiciliary Visits
We cannot accept a self-referral if you are under 16 years of age. However, your parent/guardian can complete this form on your behalf. *Fields are required.

Full Name * NHS No *
Hospital No * DOB *
Address * Postcode *
Telephone No * Email *
Mobile Number * Gender *  
Replacement of existing Orthosis
Review of existing Orthosis
Description of Orthosis *
If other, please describe
Date last issued (if known)
Relevant Medical Details (with dates of diagnosis) *
Additional Contact Details (Name and Telephone Number)
GP Name *
GP Address *
GP Telephone Number: *
Referred By: *
As part of providing you with direct care, the Trust may have to share your information with other partner organisations. To find out more information about this, please refer to our Privacy Policy.

By submitting this form, I am giving permission for the Trust to use my data and agree to the Trust contacting me using the details given above.. I understand that the Trust will:
  • securely store the information relating to my referral (and subsequent care, where applicable) in paper and/or electronic format
  • keep the records for as long as required in the Records Management Code of Practice for Health and Social Care 2016 (or for longer if it is appropriate)
  • confidentially destroy records when necessary


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