Download Self-referral North Sefton - Southport and Ormskirk Hospital NHS Trust

SELF REFERRAL FORM FOR PODIATRY ASSESSMENT
Please complete
fully using BLOCK
CAPITALS.
1) PERSONAL DETAILS:
Mr/Mrs/Ms/Miss Surname…………………………………………………………………
Forenames …………………………….Date of Birth…………………………………….
Address……………………………………………………..……………………………….
………………………………………………………………………………………………..
Post code………………………….Tel No………………………………………………..
GP Name and Surgery…………………………………………………………………….
Carers Name …………………………………………………….Tel No ………………..
Please tick all boxes
that relate to any
diagnoses given to
you by a Doctor.
This will help to
prioritise your
application.
2) MEDICAL CONDITIONS:
 Lower limb

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

Please note any
conditions that have
not been covered in
the above box.
amputation
Poor Circulation
Diabetes
Neurological
Conditions (e.g.
Parkinson’s, Stroke)
Terminal Illness








Osteoarthritis
Rheumatoid Arthritis
Steroid Therapy
Skin Conditions (e.g. Psoriasis / eczema)
Registered Blind
Joint Replacements
Learning Disability
Anticoagulant Therapy
3)PLEASE LIST ANY OTHER MEDICAL CONDITIONS:
……………………………………………………………………………………………………
………………………………………………………………………………………..
……………………………………………………………………………………………..
Please give details of
all prescribed
medication that you
are currently taking.
Please tick any boxes
that apply as this will
ensure that you are
allocated to the most
appropriate clinic for
assessment.
4)MEDICATION
Please list all current medication or attach a copy of your prescription if
possible……………………………………………………………………….
…………………………………………………………………………………
…………………………………………………………………………………
5) REASON FOR APPLICATION
 Foot Infection
 Painful corns or callous
 Ulcers / Open Wound
 Heel Pain
 Ingrown toenail
 Fungal infections
 Loss of feeling in feet
 Advice
 Footwear Advice
6) NATURE OF FOOT PROBLEM
In your own words
please provide as much
information as possible. In your own words please state the nature of your foot problem
…………………………………………………………………………………
…………………………………………………………………………………
If you are completing
this form on behalf of
someone else, please
also state your
relationship to the
patient here.
7) Signature………………………………..Date…………………………..
Relationship to applicant…………………………………………………….
SELF REFERRAL FORM FOR PODIATRY ASSESSMENT
PLEASE READ THIS IMPORTANT INFORMATION BEFORE COMPLETING
THE APPLICATION FORM.
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.
The aim of the Podiatry Service is to decrease pain, increase patient mobility and help to
increase the quality of life for patients. We will try to cure foot problems wherever possible and
aim to provide people with the means to look after their own foot health in the future.
We are unable to offer a service to those patients with no relevant
medical conditions who require routine nail cutting & minor callus
removal only.
Once we have received your application, a senior member of staff will determine its priority
according to its urgency. You will be notified of your appointment either by letter or telephone
call. Low priority applications may take up to 12 weeks to be appointed.
We often offer a package of care for a specified period of time, after which your treatment plan
will then be reviewed.
HOW TO COMPLETE THE APPLICATION FORM
Please complete the form in black ink. Complete all sections fully, in order that we can assess
the priority of your foot condition. The notes in the column on the left are to assist/prompt you
when completing the application form.
Once you have completed the application form please return it to:
Podiatry Department
Southport Centre for Health &
Wellbeing
44-46 Hoghton St
Southport
PR9 0PQ
Or by hand to your local clinic
Including:
Churchtown Community Clinic
Ainsdale Centre for Health and
Wellbeing
Formby Clinic
Southport Centre for Health and
Wellbeing