Patient Name: Patient NHS Number:

Hertfordshire Podiatry Service
HarpendenMemorialHospital
Carlton Road
Harpenden
Hertfordshire
AL5 4TA / Tel: 01582 711544
Fax 01582 765537
URGENT referrals should be faxed to:
01582 765537

HERTFORDSHIRE PODIATRY SERVICE

APPLICATION FORM

(East and North Hertfordshire patients)

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Patient Name: Patient NHS Number:

Access to treatment depends on your specific foot and health problems. Unfortunately we are unable to provide treatment for nail cutting, footwear-related corns and callus and non-painful foot problems unless your feet are at risk. Access is limited to ensure that people who are at risk receive the treatment they need from our service.

Examples of the conditions that can put your feet at risk are diabetes, poor circulation, a history of ulceration or infection, reduced sensation in the feet, rheumatoid disease, and immunosuppressant or steroid medicines. (This list is not exhaustive).

The Podiatry Service does not undertake home visits.

Please complete all sections in ink and use block capitals. If all sections are not fully completed, there may be a delay in processing your application.

After assessing the details on your referral you will either:

  • Be offered an appointment with follow-up treatments for your foot problem.
  • Be offered an intensive course of treatment and discharged.
  • Be discharged.

For children under 16 years of age a parent/guardian must attend each appointment.

If you fail to attend your assessment appointment or a follow-up appointment without notification, or repeated consecutive cancellation, you will automatically be discharged, unless there are exceptional circumstances.

January 2015

1. Patient details
Mr/Mrs/Ms/Child/Other (please circle) / Forename: / Surname:
NHS No: / Male / Female (please circle) / Date of Birth:
Address:
Postcode:
Patient Contact details
Home Phone No: / Mobile No:
 Please tick if you do not wish to be contacted by SMS (texting) / Work No:
Emergency Contact/Next of kin
Relationship to patient:
Mr/Mrs/Ms/ Other
(please circle) / Forename: / Surname:
Address:
Postcode:
Contact phone number: / Mobile No:
GP Details
GP Name: / Surgery address:
Postcode:
GP Phone No: / GP Fax No:
2. Special Requirements (Please tick relevant box) / Yes / No
Interpreter
Wheelchair user
Are you on the Learning Disabilities Register
Are there any adjustments we need to make for you?
3. Foot problem/reason for application (please complete this section to determine urgency)
Describe:
How long have you had this problem?
(Please tick relevant box) / Yes / No
Redness?
Swelling?
Weeping?
Pain/discomfort/stopping you doing activities?
If Yes, please circle below on a scale 1 – 10. 1 Low / 10 High
1 2 3 4 5 6 7 8 9 10
Have you consulted anyone else or received treatment for this foot condition? If Yes, please provide details below:
4. Medical Details – General Health, please answer all questions. All treatment is based on medical need.
Do you suffer from: (please tick relevant box). / Yes / No
Diabetes?
Rheumatoid Disease?
Kidney Disease?
Suppressed immunity?
Neurological disorder eg Multiple Sclerosis?
Blood borne infection eg HIV, hepatitis?
Any allergies. If Yes please provide details below.
Do you have a history of: (please tick relevant box). / Yes / No
DVT, Phlebitis or Cellulitis?
Foot ulceration?
Have you had a stroke?
Have you ever been diagnosed with: (please tick relevant box). / Yes / No
Poor circulation in feet and legs?
If Yes, please provide information below
5. Are you currently seeing a consultant for any reason? / Yes / No
If Yes, please give details below, including which consultant, hospital and reason for consultation
6. Have you ever been in hospital for anything or had any operations? / Yes / No
If Yes, please give details below:
7. Please give details of your:
Height: Weight: Shoe size:
8. Please list all medication below that you are taking, or attach a copy of your repeat prescription form, or ask your GP surgery to print out your health summary and attach it to this application.

Please give details here of any other relevant information that you think should be taken into account.

I confirm that the above information is correct and accurate to the best of my knowledge/consent.

Signature of person completing the form: ______Date: ______

Name (please print) ______Relationship to applicant: ______(if not the patient)

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