Podiatry online referral form Use this form to apply for a podiatry assessment. Please note – the Podiatry Service does not provide a nail cutting or general footcare service. Before completing our application form, please check our criteria below to see if we provide the service you need. We treat a range of foot conditions where there is a medical need, including: • Painful toenails, including ingrown toenails* • Painful corns* • Open wounds below the ankle for four weeks or longer • Children with foot pain • Sudden red, hot, swollen foot with or without an open wound • Assessment and treatment of musculoskeletal problems associated with walking or running. • A foot problem and a medical condition that poses a risk to the feet, for example, diabetes, rheumatology consultant patients, renal consultant patients, patients with confirmed peripheral arterial disease and chemotherapy patients. *You will be managed and then discharged once your treatment is completed. If you have a condition we can help with, please complete an application form for assessment. We are unable to provide: • Nail cutting for those who are unable or anxious, including: • Those on blood thinners • Routine footcare for those who have diabetes but have not been formally assessed as ‘high risk’ for foot problems. • Those who cannot reach their feet or grip nail clippers. • Treatment if your problem is footwear related. • Dry skin treatment. • Treatment of skin infections and verrucae. • Treatment of fungal nails. • Treatment of position or postural problem without pain, for example: - Flat feet/fallen arches - Uneven wear patterns to shoes - Bunions or toe deformities - Like-for-like replacement of worn-out insoles or orthotics issued for heel pain. If we do not offer a service you need, we advise you to talk to your GP, pharmacist or private chiropodist/podiatrist for advice. Application for podiatry assessmentNHS number:* Title: Mr Mrs Miss Ms Dr Other/no title First Name:* Last Name:* Date of birth:*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient's full address:*Preferred telephone number: Email address: Are you happy for us to send messages to/leave messages on this number? Yes No GP name and address:Emergency contact: Contact details for emergency contact:Does the patient require an interpreter? If so, which language?*Please clearly describe your foot problem:*How long have you had this problem and what have you already tried?* Have you been seen by the Podiatry Service for this problem before?* Yes No If yes, what has changed?How much pain does your foot problem cause (from 0 to 10)?*0 - no pain12 - mild pain34 - moderate pain56 - distressing pain78 - severe pain910 - worst pain possibleAre you diabetic?* Yes, I have diabetes No, I don't have diabetes Do you have an open wound?* Yes No Has your wound been present for four weeks or more?* Yes No Not applicable This patient has been referred by:* Self Carer/relative Healthcare professional Name and relationship of the referrer (if not the patient): Please upload an image of your problem if you have oneMax. file size: 25 MB.Religious affiliation (please check one) Prefer not to say Baha'i Buddhist Christian Hindu Jain Jewish Muslim Pagan Sikh Zoroastrian No religion Other Sexual orientation (please check one) Prefer not to say Heterosexual Bisexual Homosexual Other Marital status (please check one) Prefer not to say Single Married/civil partnership Divorced/dissolved civil partnership Widowed/surviving civil partner Separated Ethnicity (please check one) Prefer not to say Bangladesh or British Bangladesh Black African Black Caribbean Any other Black background Chinese Indian or British Indian Mixed White and Asian Any other White background Mixed White and Black African Mixed White and Black Caribbean Pakistani or British Pakistani Any other Mixed background White British White Irish Any other Asian background Any other ethnic group
