Self-referral Form

Bristol, North Somerset and South Gloucestershire CCG

Osteoarthritis Hip or Knee

To attend one of our services in the Bristol, North Somerset and South Gloucestershire 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

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

Patient Information

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.

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.

Access requirements (please select as appropriate):

By submitting this form I am consenting to Versus Arthritis using this data to communicate with my registered Hospital, to update them that I have attended this service.

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