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GP Referrals

GP Referrals

GP Referral Forms

We welcome referrals from GPs and healthcare professionals.

Please complete the appropriate form below or download a copy to submit via email.

How to Refer a Patient

Complete the relevant online referral form

Or download

a form and email directly

Or email a

referral letter directly

We will contact the patient to arrange an appointment

Female Referral Form

Male Referral Form

Child / Adolescent Referral Form

Downloadable Resources

Child / Adolescent Referral Form

Please complete the form below for outpatient paediatric pelvic health physiotherapy referrals.

Patient Information Section

Patient Name*

Date of Birth*

Day

Month

Year

Address*

Diagnosis*

Referral Type*

Parent Name*

Parent Contact Number*

Parent Email Address*

GP / Referrer Name*

GP / Referrer Address*

GP / Referrer Contact Number*

GP / Referrer Email Address*

Reason for Referral

Options:*

Urinary incontinence

Chronic constipation/obstructive defecation

Bet wetting/ nighttime wetting

Recurrent UTI’s

Difficulty progressing with potty training

Daytime wetting

Other

Neurodiversity Diagnosis (if applicable)

Medical Conditions

Medication

Any Other Relevant Information

Referral Date*

Day

Month

Year

Male Pelvic Health Referral Form

Please complete the form below for outpatient male pelvic health physiotherapy referrals.

Patient Information Section

Patient Name*

Date of Birth*

Day

Month

Year

Address*

Diagnosis*

Referral Type*

Contact Number*

Email Address*

GP / Referrer Name*

GP / Referrer Address*

GP / Referrer Contact Number*

GP / Referrer Email Address*

Reason for Referral

Options:*

Urinary incontinence (stress / urge / mixed / incomplete emptying)

Flatal incontinence

Faecal incontinence (stress / urge / passive)

Chronic constipation / obstructive defecation

Post RRP or radiotherapy treatment for prostate cancer

Painful pelvic floor conditions (pelvic pain / prostatitis)

Painful bladder symptoms (Interstitial Cystitis / recurrent UTIs)

Sexual dysfunction (Erectile dysfunction, premature ejaculation, hard flaccid syndrome, reduced orgasm quality, anorgasmia, pyrones disease )

Other

Have they been screened for DTI/STD?

Yes

No

if YES please attach results

Has there been a PSA completed in the past 12 months?

Yes

No

if YES please attach results

Has a recent MSU been completed (at least 6 weeks prior to referral)?

Yes

No

Medical Conditions

Medication

Any Other Relevant Information

Referral Date*

Day

Month

Year

If you experience any issues uploading files, relevant screening results (PSA, MSU, STI/STD screening) can also be emailed separately to gwpelvichealth@gmail.com.

Female Pelvic Health Referral Form

Please complete the form below for outpatient female pelvic health physiotherapy referrals.

Patient Information Section

Patient Name*

Date of Birth*

Day

Month

Year

Address*

Diagnosis*

Referral Type*

Contact Number*

Email Address*

GP / Referrer Name*

GP / Referrer Address*

GP / Referrer Contact Number*

GP / Referrer Email Address*

Reason for Referral

Options:*

Urinary incontinence (stress / urge / mixed / incomplete emptying)

Flatal incontinence

Faecal incontinence (stress / urge / passive)

Chronic constipation / obstructive defecation

Post radiotherapy or chemotherapy treatment

Painful pelvic floor conditions (pelvic pain / sexual pain / pain on examination)

Painful bladder symptoms (Interstitial Cystitis / recurrent UTIs)

Postpartum care

Breastfeeding support (mastitis / cracked nipples)

Scar healing (surgical / episiotomy / OASIS tears)

Antenatal care

Other

Medical Conditions

Medication

Any Other Relevant Information

Referral Date*

Day

Month

Year

We’ve included referral guidance and patient information leaflets below to support GPs, healthcare professionals, and patients.

These resources can be downloaded and shared where needed.

Download GP Referral Guide

Download Health Clinician Referral Guide

Download Women’s Information Leaflet

Download Men’s Information Leaflet

Download Children’s Information Leaflet

Download Female Referral Form

Download Male Referral Form

Download Child Referral Form

Alternative Referral Option

Referrals can also be submitted by emailing a referral letter directly, if preferred.

This may include dictated letters or written referrals in place of completing the forms.

gwpelvichealth@gmail.com

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Email

gwpelvichealth@gmail.com

Address

Unit B14, KCR Business Park,

Ravensdale Park, Dublin 12, D12 P681

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