Self-referral Form - East Riding of Yorkshire CCG

Osteoarthritis Hip and/or Knee

Please note: You will need to be registered at a GP surgery in the local area of the East Riding of Yorkshire to access our services.

To attend one of our services in the East Riding of Yorkshire area please complete all the fields below and submit the form. Once we receive your form one of our members of staff will contact you within 10 working days to confirm your service with us.

If you’re having trouble completing the below form, please either contact us on: 0300 790 0433 or contact your GP and ask them to refer you to Versus Arthritis Shared Decision-Making Service.

Phone lines are monitored Monday – Friday 9am – 5pm.

For your information, our service is in high demand at the moment, we are working hard to provide a service to people as quickly as possible, but please note you may need to wait a few weeks for an appointment.

Patient Information

First name

Surname

What is your sex?

Male

Female

i.e. what is recorded on your legal documents such as a birth certificate, Gender Recognition Certificate, or passport?

Please note we recognise the diversity of gender identity but in this case need to ask biological sex.

What is your ethnicity?

Date of birth

NHS number

We require your NHS number as this is a service commissioned by your local NHS Clinical Commissioning Group, and it forms part of the health and care support you receive for your osteoarthritis. You can find your NHS number on any repeat prescription, on your online patient access account, on your NHS app, or you can contact your GP and ask for it.

As our services are commissioned by East Riding of Yorkshire CCG, you're GP Surgery must be registered to East Riding of Yorkshire CCG to be able to register for our service. Only Registered GP Surgeries will be listed below after the form.

Address1

Address2

City

Postcode

Phone

Alternative phone number

Email

GP surgery

Health condition

Hip osteoarthritis

Knee osteoarthritis

Both

Our services are delivered as either individual 121 sessions or group sessions. Please select below your preference. Please note: we will endeavour to offer you your prefered session but this may not always be possible.

Individual 121

Group session

No preference

Alternative language requirements

Yes

No

Please add details

Physical access requirements

Yes

No

Please add details

I confirm I understand that this service provided by Versus Arthritis is only for hip and knee osteoarthritis information and that no other information attaining to other joints will be given.

By submitting this form I am consenting to Versus Arthritis using this data to communicate with my registered GP, to update them that I have self-referred myself to this service.

For more information on how we protect and use your personal information, please see our privacy notice.