This Application Form Is for Use by a Health Professional Only

This application form is for use by a Health Professional Only.

Please read the following information to help you complete the application.

The information you provide on this referral form will be used to triage the patient re eligibility for podiatry assessment. The more detailed the information provided, the easier it will be to determine priority.

All patients are notified in writing whether or not a podiatry assessment appointment will be offered.

NHS Podiatry is a service provided primarily for those people that have a medical condition that may adversely affect their feet.

Eligibility is not related to age.

The following conditions are given priority: Diabetes, Vascular Disorders, Neurological Conditions, Inflammatory Disease e.g.: Rheumatoid Arthritis, Foot Ulceration or Infection.

We are unable to offer a service to patients with no relevant medical conditions who require routine nail cutting or treatment of verrucae

Demand for domiciliary visits is very high.

Applications for Domiciliary assessments will only be considered if the patient iscompletely housebound. If the patient attends appointments at any other health centre / hospital department or can travel by taxi or car then they will be asked to attend clinic for podiatry. If there are special circumstances that require a patient to be visited at home, please tell us on this form.

Please complete all sections of this form and return the completed application to:

Podiatry Department

Southport Centre for Health & Wellbeing

44-46 Hoghton Street

Southport

PR9 0PQ

Tel: 01704 385097

Fax: 01704 385103

IF YOU CONSIDER A REFERRAL TO BE URGENT PLEASE SEND IT VIA FAX

PATIENT DETAILS:

TITLE: MR / MRS / MISS / MS / DR

FIRST NAMES …………………………….. SURNAME…………………………………………

ADDRESS……………………………………………………………….POSTCODE……………

TEL:……...………………………DATE OF BIRTH…………………… GP:……………………..

ETHNICITY…………………………………… SMOKING STATUS …Smoker / Non-Smoker…

Carers Name …………………………………………………….Tel No…………………………..

REASON FOR REFERRAL:( tick all that apply)

The service does not provide simple nail careor treatment of verrucae

FOOT ULCER  RHEUMATOID FOOT CONDITIONS

SUSPECTED CHARCOT FOOT  DIABETIC FOOT CONDITIONS

CALLUS / CORNS  INGROWING TOENAIL

BIOMECHANICAL ASSESSMENT / INSOLES ABPI

Please specify the following:

 DOMICILLIARY VISIT REQUESTED  CLINIC APPOINTMENT

 URGENT /  NON URGENT

DOES THE PATIENT HAVE A HISTORY OF ANY OF THE FOLLOWING?:

PVD (Please supply any information relating to pedal pulses, Doppler readings or Vascular surgery if known)

…………………………………………………………………………………………………………

DIABETES - Please indicate Glycaemic control if known:

Good Erratic Poor Most recent HbA1c………….mmol/l

 NEUROPATHY (please specify type)

 PREVIOUS ULCER/ LOWER LIMB AMPUTATION (please give details)

…………………………………………………………………………………………

RELEVANT MEDICAL HISTORY– Please attach patient’s medical history

……………………………………………………………………………………………………………………………………………………………………………………………………………………

CURRENT MEDICATION – Please attach a list of patient’s current medication. ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

DETAILS OF PRESENTING FOOT COMPLAINT:

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

REFERRED BY:

NAME:…………………………………………… JOB TITLE:……………………………….

CONTACT PHONE NO:……………………………. DATE:…………………..

IF THIS FORM IS INCOMPLETE, IT WILL BE RETURNED TO YOU