Lambeth and Southwark Community Foot Health Services referral form

It is important that all fields are completed as missing information may cause a delay.

Forms should be returned via ERS or can be emailed to: Email:

Address: Podiatry Centre, ArtesianBuilding, 94 Alscot Road, Bermondsey, SE1 3GG Tel: 0203 049 7900 (option 2)

IMPORTANT: If you are housebound and unable to attend a clinic please ask your GP or other healthcare professional to refer you using this form via the above email or post address.

Referrer details
Please complete this section if you are referring somebody other than yourself
Name / Organisation
Address
Post code
Contact number
Is the person you are referring housebound? / Y / N
Patient details
Title (Mr/Mrs/Miss) / First name / Last name / Date of birth
/ /
Address
Post code
Home tel number / Mobile Tel number
Email address
if you would like to be contacted via this method
NHS number
if known / Interpreter required / Y / N / If yes, which language
General Practitioner details
GP name / Dr
Practice address
Post code
Contact number
General Health
If you have no medical problems please tick this box  otherwise review below and tick if you have been diagnosed with;
Yes / No / Yes / No
Diabetes / Liver/kidney problems
Leg/foot circulation problems / Arthritis
Neurological problems / Learning disabilities
Heart problems / Dementia
Chest/breathing problems
Any additional information
Details of any operations
Any known allergies
Medication
Please tick here if you take no medication  otherwise please list any medication you take, to include tablets, creams and inhalers. You can attach a prescription sheet if easier.
Foot problem
Please give further information on why you are requesting a foot health assessment including how long you have had the problem.
About you
What is your occupation?
If you use a wheelchair are you able to transfer to a treatment couch? / Yes / No
Can you see well, either with or without glasses?
Can you reach your feet?
Please select a preferred clinic from the list below
(some specialist services are only available atcertain clinics, you will be advised if appropriate)
Clinic name / Address / Tick
Akerman Health Centre / 60 Patmos Road, Brixton, SW9 6AF
Artesian Podiatry Centre / Artesian Building, 94 Alscot Road, Bermondsey,SE1 3GG
Clapham Manor / 86 Clapham Manor St, Clapham, SW4 6EB
Elmcourt Health Centre / 214-218 Norwood Road, Norwood, SE27 9AW
Gaumont Surgery / 153 Peckham High St, Peckham,SE15 5SL
GracefieldGardens / 2-8 GracefieldGardens, Streatham, SW16 2ST
Lambeth Community Care Centre / Monkton Street, Kennington, SE11 4TX
Mawbey Brough Health Centre / 39 Wilcox Close, Vauxhall, SW8 2UD
Townley Road Clinic / 221 Townley Road, EastDulwich, SE22 8SW

Community Foot Health patient information

What happens next?

  • Your referral form will be reviewed by a podiatrist. It is therefore important that you provide as much information so we select the correct clinic for you.
  • Our Referral Management Centre will contact you by telephone/email within two weeks (and by post if we are unsuccessful in contacting you) to agree a clinic location, date and time suitable to you.
  • If you do not hear from us within this time please call on 0203 049 7900, Monday to Friday 9am to 4:45pm.

At your assessment appointment

  • You will be assessed by a podiatrist who will discuss the significance of your foot problem with you and if appropriate, treatment will be started.
  • You may need an episode of podiatry care and the number and frequency of the appointments will be agreed with you.
  • You may need an episode of podiatry care with a specialist podiatrist following your first appointment. This will be arranged with you but please note it may not be at the closest clinic location to you.
  • You may be given advice on how you can manage a foot health problem effectively yourself and therefore will not require further appointments.
  • We will provide verbal and written information to you at your appointment and there will be time for any questions you may have.

Emergency clinics / We provide emergency clinics if you think that your foot problem is urgent. Examples of this are bleeding, swelling and infection.
Please see clinic location list and times below where the podiatrist will provide assessment, advice and treatment if appropriate. Clinics can become busy so please be prepared to wait. Complete this form and take it to the reception desk at your preferred location.
Day / Time / Clinic / Address / Telephone
Monday / 1:30pm -3:40pm / Gaumont Surgery / 153 Peckham High St
PeckhamSE15 5SL / 0203 049 7900
Monday / 1:30pm -3:40pm / Manor Health Centre / 86 Clapham Manor St
Clapham SW4 6EB
Tuesday / 1:30pm -3:40pm / GracefieldGardens / 2-8 GracefieldGardens
Streatham SW16 2ST
Wednesday / 9:50am -12:30pm / Elmcourt / 214-218 Norwood Road
NorwoodSE27 9AW
Wednesday / 1:30pm -3:40pm / Podiatry Centre
Artesian / Artesian Building
94 Alscot Road
Bermondsey SE1 3GG
Thursday / 1:30pm -3:40pm / Mawbey Brough Health Centre / 39 Wilcox Close
Vauxhall SW8 2UD
Friday / 1:30pm -3:40pm / Mawbey Brough Health Centre / 39 Wilcox Close
Vauxhall SW8 2UD
Friday / 1:30pm -3:40pm / Podiatry Centre
Artesian / Artesian Building
94 Alscot Road
Bermondsey SE1 3GG

Helping us to understand more about the patients and the community we serve

Guy’s and St Thomas’ is committed to diversity and equal opportunities for all. Collecting this information enables us to have a better picture of any particular needs of our diverse patient community. This information is to help us monitor the effectiveness of our equality and diversity policies and to help comply with legal requirements.

1.Who is the main person answering the questions below?
□Patient / □Carer/family member / □ Both patient and carer together / □Other
2.Have you ever visited the Podiatry department before?
□Yes / □ No
3.Are you?
□Male / □Female / □Prefer not to say
4.What age group are you?
□Replying on behalf of a child under 16 / □18-24 / □25-34 / □35-44 / □ 45-54
□55-64 / □65-74 / □75-84 / □ 85+ / □Prefer not to say
5.What is your sexual orientation?
□Bisexual / □Gay man / □ Gay woman/lesbian
□Heterosexual/straight / □Other / □ Prefer not to say
6.What would you consider to be your ethnic background?
□ White British / □White
Irish / □Any other white background / □Indian / □Pakistani / □Bangladeshi
□Any other Asian background / □Black Caribbean / □Black African / □Any other Black background / □Chinese / □White and Black Caribbean
□ White and Black African / □White and Asian / □Any other mixed background / □Other / □Prefer not to say
7. What is your religion?
□ Buddhist / □ Christian / □Hindu / □Jewish / □Muslim
□ Sikh / □Other / □ No religion / □ Prefer not to say

Thank you for your time!

Data protection statement

Thank you for taking the time to complete our survey. The information you have provided will be treated confidentially. The comments that we have received will not be attributed to any individuals. This information is also used by the Foundation Trust to help us monitor the effectiveness of our equality policies and to help comply with legal requirements.