Patient Self-Referral to Podiatry Services

Please note: if you are under the care of the podiatry team, you do not need to complete this form. Please contact the bookings team on the contact details below.

This form should only be used for patients (over the age of 18) wishing to have Podiatry for foot related problems.

We do not treat verrucas and we do not see patients for basic nail cutting unless they have a medical need (such as diabetes) which put their feet at risk of complications, and are unable to manage their own foot care needs.

Your referral will be rejected if it does not meet the Podiatry Service Criteria for treatment; if this is the case, you will be informed by post.

Appointment queries: Tel: 020 3316 1111 / 0203 316 1600 (10- 4pm) or email: arti.centralbooking@nhs.net / haringey.adult-referrals@nhs.net

Please ensure all the fields marked* are filled in correctly.

I confirm that I am happy to receive information by* Email
Mobile

Please provide details*

Patient details

Surname*

First name*

Gender* Female
Male

Date of Birth*(dd/mm/yyyy)

Home Address and Postcode*

Daytime number*

Mobile number*

NHS No.(if known)

Hospital No

Is an interpreter required?* Yes
No

How would you describe your ethnic origin*

Next of kin*

Home Address and Postcode*

Telephone number*

GP details

GP Practice*

GP Name

GP Address*

GP Telephone number

Have you consulted your GP about this problem?* Yes
No

If Yes, what did they recommend

Give a brief description of your problem including how it started.(please only refer for one condition)*

Area of pain / How it started /Any previous treatments?

How long have you had this problem?* Less than 2 weeks
2 – 6 weeks
More than 6 weeks
More than 1 year

Is your problem?* Getting better
Getting worse
Staying the same

Have you had any investigations for this problem? (E.g. Scans, X-rays, Blood tests)* Yes
No

If Yes, please give details:

General Health - Please tick if you have any of the following:

Lung Problems

Heart Problems

Epilepsy

Osteoarthritis

Rheumatoid Arthritis

Osteoporosis

Diabetes

Surgery / Operations

Previous Fractures

Current or Past Pregnancy

Any Major Illness

If Yes to any, please give details

SINCE THE ONSET OF THIS PROBLEM Do any of the following apply to you? If you have the symptoms please tick

Areas of the foot which are red/swollen/hot/inflammation

Open wounds on the foot (especially if you are diabetic)

Foot ulcer

Feet which are cold/dusky/painful

Night cramps or cramps when walking a short distance in legs

If you have ticked any of these symptoms, and you HAVE NOT seen a doctor for this symptom, it is essential you arrange an appointment with your GP

DO NOT SEND IN THIS FORM UNTIL YOU HAVE SOUGHT FURTHER ADVICE

Please list any Medicine you are taking (leave blank if not on medication)

Employment status* Employed
Unemployed
Retired
Student
Carer

Please give details

Any activities you do (E.g. Sports, Gym, Hobbies). Please give details:*

Due to your current problem you are unable to:

Work

Participate in activity/sport

Care for dependent

Other

Please give details

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