Request for NHS Podiatry services
Please ensure All sections are completed – failure to complete them may mean that this form is returned to you and treatment may be delayed or refused.Title - MR / MRS / MS / MISS / ______Date of Birth _ _ /_ _ / _ _
NHS No. ______
Surname
First Name(s)
Address
Post Code ______
Tel Home
Tel Mobile
Emergency contact: Name, Relationship to you and Tel No.
/ GP Name
Address
Post Code ______
Tel
Do you require any adjustments in order to be seen in clinic? e.g. language interpretation, sign language etc. Please give details
No Yes
Please list any medical conditions you have. Please provide as much detail as possible to enable us to triage your referral accurately.
Patients with diabetes (to be completed by GP if required)
Active
HBA1C recent results: Last diabetic review date:
Additional information
Please list your medication (or if possible attach a prescription)
Reason for application
What foot problems do you have that require treatment? (please give as much detail as possible)
Based on your above medical history the conditions we assess are: Diabetic foot complications, management of long-term foot conditions or deformities, bacterial infections of the skin or nail, painful musculoskeletal conditions, U18 biomechanical conditions, painful or complicated nail and skincare.
Have you previously had a foot ulcer? Yes No
Have you had any lower limb amputations? Yes No
Do you attend a renal dialysis unit? Yes No
Is there any foot deformity that cannot be accommodated in a well-fitting shoe? Yes No
Have you got a current bacterial infection of the foot that you are taking antibiotics for? Yes No
Print name
Signature
Date
Your relationship to the patient if you are completing on their behalf
/ Office use only.
Triage Date …... / …... / …...
Triaged By
Eligible Not eligible
Telephone triage Leaflet required
Grid position
Routine BOT Urgent