Please only complete this form if you are pregnant or are within 12 months of giving birth.

Alternatively, you can call and register a self-referral: 0161 922 4888, Option 3.

For pelvic girdle pain please complete the separate PGP self-referral form.

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If you are pregnant, please complete this section indicating your symptoms:
If you have given birth in the past 12 months, please complete this section indicating your symptoms: Required
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