IMPORTANT

If you have diabetes and a foot wound, or you think your foot is infected, or you feel unwell please IMMEDIATELY seek medical help from your GP or:

If you do not have diabetes but have a serious foot problem that needs immediate attention, or foot infection or you feel unwell, please contact your GP, 111 or A&E
About Self-Referrals

The Podiatry Service is for individuals who meet the eligibility criteria for the service. In general, this is for “feet in need” to prevent life and limb threatening complications.

There is a prioritisation of services to service users based on their clinical need:
  • We do not treat nails unless linked to another problem, e.g. they risk causing wounds
  • We do not collect samples for fungal assessment
  • We do not treat verruca
  • We do not treat corns or callouses without a medical condition that puts the foot at risk.
  • We do not treat asymptomatic “flat feet” e.g. flat feet but no pain

Failure to complete ALL sections will result in the application form being returned and may delay your assessment.

The referral wil be triaged by a member of the Podiatry team and, if accepted, an appointment will be made for you. If deemed ineligible you will be not be offered an appointment.

Any information you provide in the Self-Referral will be handled in accordance with the Trust's Privacy Notice

Patient Details
Accessibility
Do you require an interpreter?

Do you have any other communication needs, e.g. sight or hearing?
What do you require help with?
Existing Conditions
* Which GP surgery are you registered with?

Are you receiving treatment for any of the following:
Diabetes
Inflammatory arthropathy e.g. Rheumatoid Arthritis
Loss of sensation in feet
Heart Disease
Poor circulation

Please specify any other medical conditions that are currently being treated and any previous medical conditions that you may feel impact on your foot problem

Please list all medications currently being taken: (attach additional documents if required)

Known allergies
How Can We Help
* Please give a description of the foot problem/reason for request. Include as much detail as possible as this will help assess how quickly you may need to be seen

For example:

  • Where is your site of pain – what type of pain is it – e.g. sharp, dull ache, throbbing?
  • Is there swelling or discharge present?
  • How long have you had the problem?
  • What have you tried already to help yourself and has this made it better or worse?
  • Do you have a fall or balance problem?

* Have you been seen by podiatry previously?




Please give any other information which you feel we should be aware of, or assistance required to help with the assessment
Mobility Assessment
* Do you have any mobility issues?
Please specify your mobility issues
Home Visit Assessment

A very limited Podiatry Home Visit Service is available in exceptional circumstances to patients who are totally housebound . We may contact your GP for further information regarding any request for a home visit.

† Definition of housebound Patients eligible for a home visit by the Podiatry Service are those who have one or more of the following:

  • Persons who are completely bedbound
  • Persons who require hoisting in order to be moved or to travel
  • Persons deemed, on a temporary basis, to be clinically too ill to be reasonably expected to travel

Patients who do not meet the above criteria are expected to attend clinics for appointments. If there are difficulties with mobility or transport, you may be able to get help to attend clinic from Patient Transport Advice Centre (PTAC) – 01278 272 457. Visits from GPs and district nurses do not automatically qualify someone for a Podiatry home visit.


* I require a home visit assessment
* I am bedbound
* I need a hoist to be moved
* I am temporarily housebound due to illness
About You
* Form Completed By
* Are you the patient?
If completed by someone else, relationship to patient