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Podiatry Self-Referral Form

Please select from the following before proceeding

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Retrieve previous referral progress

Email Address

Reference Number

Verification Code (Please enter the code emailed to you)

DATA PROTECTION NOTICE
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Please complete this form to self refer to NHFT Podiatry service

Section 1

Title

*Legal first name

*Legal surname

E-Mail Address

*Address

Home Telephone Number

Mobile Number

Preferred Phone Contact Method

*Date of Birth

Occupation

Next of Kin: Name

Next of Kin: Tel number

Next of Kin: Relation to patient

GP Name

*GP Surgery

GP Contact Number

*Is this referral for yourself?

Reason for Referral

*Where on your foot is the problem?

Bottom of Left Foot

Top of Left Foot

Bottom of Right Foot

Top of Right Foot

Pain in Left Heel

Pain in Right Heel

Other

*Brief description of the problem

*How long have you had this problem? (Days / Weeks / Years)

*Is your problem painful?

If yes, is it

*Are there signs of

*Have you received any medical/nursing help for this problem? If yes please give details

*Have you seen a Podiatrist/Chiropodist in the last year? If yes, where did you receive treatment?

All treatment is based on medical needs. Please Tick Yes or No on each item on the list below to state whether you are currently suffering or have previously suffered from any of the following conditions

	Yes	No
*Diabetes
*Circulation Problems (e.g., Raynaud's, history of lower limb gangrene, amputation, stents, by-pass surgery or angioplasty)
*Immunosuppression (e.g., Renal problems, chemotherapy)
*Rheumatoid Arthritis
*Osteoarthritis
*Chest/Breathing Problems
*Stroke
*Heart Problems
*Physical disability/disabilities
*Registered blind or partially sighted
*Severe Learning Difficulties
*Congenital problems
*Neurological problems (e.g., Multiple Sclerosis, Parkinson's disease, paralysis)
*Terminal illness

*Please state any other ailments not listed

*Please list any known allergies (eg penicillin, latex, local anaesthetics, cat fur, hay fever) or please type none if you have no allergies

*Medication - Please list all tablets and medicines that you take, please include injections and chemotherapy (Check your repeat prescription form).

Who normally cares for your feet ie self, Relative, Partner, Other (please specify)

IF this has changed, please explain why

*Are you a military veteran

*Consent to contact your GP for additional information

NHFT Referral Forms

Podiatry Self-Referral Form

Please select from the following before proceeding

Section 1

Reason for Referral

Thank you for submitting a referral. Your response has been recorded.