Letter Contact

Self-Referral – Contact Us

Thank you for completing the self-referral form. Your responses indicate that you may be eligible for the D-MAPP study. Please complete and submit the form below and the trial team will be in touch.

This page will need a brief privacy statement to cover it for GDPR.

Please enter your patient ID number from your invitation letter *

Title *

Name *

First

Last

Date of Birth *

Phone Number *

Email Address *

Name of GP surgery *

2. How would you rate the pain caused by your condition? *

• Mild
• Moderate
• Severe

Name of secondary care site eg. Physiotherapy/Rheumatology clinic (if you have one)

How do you currently manage your condition? *

• At home using advice from my GP
• I see an NHS physiotherapist
• I attend private physiotherapy sessions
• I see a consultant at my local hospital
• Other, please give details (enter below)

If Other, please provide details

How would you usually access the internet? (select all that apply) *

• Computer/laptop via home broadband
• Tablet via home broadband
• Mobile via home broadband
• Mobile data via mobile phone provider
• At work
• Free WiFi away from home (e.g., at a café)
• Other, please provide details

If Other, please provide details

Is your local hospital one of the following (please select) *

• Centre 1
• Center 2
• None of the above (you will be referred to the research team at Leeds Teaching Hospitals NHS Trust)

Submit