Metro North Hospital & Health Service
Subacute and Ambulatory Service
High Risk Foot Podiatry Service Referral Form / (Affix patient identification label here)
URN:
Family Name:
Given Names:
Address:
Date of Birth: Sex: M F /
ATTACH A DISCHARGE /MEDICAL SUMMARY TO THIS REFERRAL
Client Consent
Yes No Reason if No Date of Referral
Client Requires Management of (Tick all that apply)
Current foot ulcer +/- infection
Acute ischaemia or necrosis
Charcot / Neuro-arthropathic joint
Previous foot ulcer or amputation
Deformity with peripheral neuropathy or vascular disease
Peripheral vascular disease
Peripheral neuropathy
Foot deformity
Clients requires nail care only (referral will not be accepted)

Client Goals for Podiatry Management

Preferred Site
North Lakes Caboolture Chermside North West Brighton Redcliffe
Relevant Medical Information/Health Conditions
Other Services Involved (State who is involved and how often the service is provided)
Other Relevant Information (eg services involved, cultural needs, risks etc)

Referrer Details

Name Address/Agency/Practice

Telephone Fax

Email Address

Hospital Details (if applicable)

Hospital & Ward Consultant Name Admission Date Discharge Date

Client Details

Title Name Sex M F Date of Birth

Address

Telephone Mobile

Indigenous Status (Drop down box Aboriginal/Torres Strait Islander/Both Aboriginal and Torres Strait Islander/Non-Indigenous)
Does the client require an interpreter? Yes No Unknown
If yes, language spoken
Does the client require assistance to communicate? Yes No Unknown
Medicare No Expiry Date
Government Benefit Card No
(Drop down box No Benefit/Aged Pension/Carers Pension/Disability Pension/Unemployment Benefit/Veteran White/Veteran Gold)
Health Insurance Card No Company
(drop down box None/Hospital Only/Extras Only/Hospital & Extras/3rd Party/Workers Compensation Motor Vehicle)
Emergency Contact
Name Address
Telephone Mobile
Relationship to Client
Does the client have an EPOA? Yes No Unknown
EPOA Name Telephone
REFERRAL SUBMISSION
Brisbane City Council area Moreton Bay Regional Council area
Fax: 3139 6522 Fax: 3049 1260
Enquiries: 1300 658 252 Enquiries: 1300 658 252

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