Here to Help Referral Form - Muscular Dystrophy UK

Please complete this short form to request support for yourself or someone else as part of our referral service

Adult Self-Referral

Please complete this short form to self-refer to Muscular Dystrophy UK’s Referral Service. We will aim to contact you within 5 working days. To provide the best support, we may securely record your name, contact details, and condition related information on our database. Only our staff can access this data to assist you. If you’re having trouble completing the form, don’t worry — you can email our support team directly at info@musculardystrophyuk.org or call our free helpline on 0800 652 6352 (Monday to Thursday, 10am to 2pm)

Phone(Required)

Email(Required)

Which language do you require phone support in?

Which hospital do you attend for your neuromuscular care?(Required)

Please specify which hospital you attend for your neuromuscular care

What is your condition or condition group?(Required)

What type of FSHD do you have?

What type of EDMD do you have?

What type of myotonic dystrophy do you have?

What type of LGMD do you have?

What type of distal myopathy do you have?

What type of congenital muscular dystrophy do you have?

What type of congenital myopathy do you have?

What type of inflammatory myopathy do you have?

What type of metabolic myopathy do you have?

What type of mitochondrial disease do you have?

What type of SMA do you have?

What type of CMT do you have?

What type of myasthenic condition do you have?

What type of muscle channelopathy do you have?

Please tell us the name of your condition(Required)

Is there anything else you would like us to know?

NHS Referral (Adult)

Please complete this short form to refer a patient or their parent/carer to Muscular Dystrophy UK’s referral service. We will aim to contact them within 5 working days. This form takes under 1 minute to complete.

NHS Email(Required)

Referrer role(Required)

Please specify your role

What hospital are you referring from?(Required)

Please provide details of the adult patient you are referring

Patient's contact number(Required)

Patient Email(Required)

What is their condition or condition group?(Required)

What type of FSHD do they have?

What type of EDMD do they have?

What type of myotonic dystrophy do they have?

What type of LGMD do they have?

What type of distal myopathy do they have?

What type of congenital muscular dystrophy do they have?

What type of congenital myopathy do they have?

What type of inflammatory myopathy do they have?

What type of metabolic myopathy do they have?

What type of mitochondrial disease do they have?

What type of SMA do they have?

What type of CMT do they have?

What type of myasthenic condition do they have?

What type of muscle channelopathy do they have?

Please tell us the name of their condition(Required)

Specific diagnosis or subtype, if known

Which language do they require phone support in?

Any other useful information to share

Parent/carer self-referral

Please complete this short form to self-refer to Muscular Dystrophy UK’s Referral Service. We will aim to contact you within 5 working days. To provide the best support, we may securely record your name, contact details, and your child’s condition information on our database. Only our staff can access this data to assist you. If you’re having trouble completing the form, don’t worry — you can email our support team directly at info@musculardystrophyuk.org or call our free helpline on 0800 652 6352 (Monday to Thursday, 10am to 2pm).

Parent/carer's contact number(Required)

Parent/carer's email address(Required)

Which language do you require phone support in?

Your child's details

Which hospital does your child attend for their neuromuscular care?(Required)

What is your child's condition or condition group?(Required)

What type of FSHD do they have?

What type of EDMD do they have?

What type of myotonic dystrophy do they have?

What type of LGMD do they have?

What type of distal myopathy do they have?

What type of congenital muscular dystrophy do they have?

What type of congenital myopathy do they have?

What type of inflammatory myopathy do they have?

What type of metabolic myopathy do they have?

What type of mitochondrial disease do they have?

What type of SMA do they have?

What type of CMT do they have?

What type of myasthenic condition do they have?

What type of muscle channelopathy do they have?

Please tell us the name of your child's condition(Required)

Specific diagnosis or subtype, if known

Is there anything else you would like us to know?

NHS paediatric referral

Please complete this short form to refer a patient or their parent/carer to Muscular Dystrophy UK’s Referral Service. We will aim to contact them within 5 working days. This form takes under 1 minute to complete.

NHS Email(Required)

Referrer role(Required)

Please specify your role

What hospital are you referring from?(Required)

Parent/carer's details

Parent/carer's contact number(Required)

Parent/carer's email address(Required)

Does the parent or carer require phone support in a language other than English?(Required)

Which language do they require phone support in?

What is their child's condition or condition group?(Required)

What type of FSHD do they have?

What type of EDMD do they have?

What type of myotonic dystrophy do they have?

What type of LGMD do they have?

What type of distal myopathy do they have?

What type of congenital muscular dystrophy do they have?

What type of congenital myopathy do they have?

What type of inflammatory myopathy do they have?

What type of metabolic myopathy do they have?

What type of mitochondrial disease do they have?

What type of SMA do they have?

What type of CMT do they have?

What type of myasthenic condition do they have?

What type of muscle channelopathy do they have?

Please tell us the name of their condition(Required)

Any other useful information to share

Preferred contact days/dates

Here to Help Referral Service Form

Please complete this short form to request support for yourself or someone else as part of our referral service

Adult Self-Referral

NHS Referral (Adult)

Please provide details of the adult patient you are referring

Parent/carer self-referral

Your child's details

NHS paediatric referral

Parent/carer's details