Pelvic health physiotherapy self-referral form
The Trust's pelvic health physiotherapy service provides physiotherapy for women and birthing people whose pregnancy is booked at Queen Charlottes & Chelsea Hospital or St. Mary's Hospital.
The form below allows self-referral into this service.
If you are booked at another hospital, please speak with your midwife or GP for a referral to your local service.
If you are looking to book into our healthy pregnancy class which is a one-time class for women who are between 12-20 weeks pregnant, which provides expert advice on having a healthy pregnancy, please email email@example.com or call on 020 3313 3072 to book into the class.
If your pregnancy is booked at Imperial, and you would like to self-refer to physiotherapy, please accurately fill in the form below.
Should you have difficulty completing the form, you can instead be referred to the Trust's pelvic health physiotherapy by your midwife, obstetrician or via the maternity helpline (020 3312 6135).
Do not refer to physiotherapy without a review from a doctor first, if you have any of the following symptoms:
- Unusual or unexpected vaginal bleeding
- Blood on passing urine
- Stinging or burning sensation when you pass urine
- Blood in your stool
- Unexplained persistent abdominal pain
- Unexplained persistent abdominal bloating that does not come and go
- Unexplained weight loss
- Numbness or pins and needles in your lower limbs
- Numbness around your buttocks or perineum
- Inability to empty your bladder
- Sudden changes in bowel habits without known cause
Please note: Your initial appointment may be in a group setting or one-to-one
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