DEPARTMENT of PODIATRY - New Patient Referral Form

DEPARTMENT OF PODIATRY - New Patient Referral Form

(Please read the reverse notes before completing this Referral Form)

THE BELOW MUST BE COMPLETED FULLY IN ORDER TO BE PROCESSED

Name:
Address: / Telephone:
Mobile:
D.O.B:
NHS No:
GP Name:
GP Surgery:
Reason for referral / foot health problem:
Medical Conditions: / Other:
Diabetes: / Yes / No
Rheumatoid: / Yes / No
Loss of sensation in feet: / Yes / No
Heart Disease: / Yes / No
Poor Circulation: / Yes / No
Medication (Please supply a list of all current medication you are taking):
Allergies:
Referred by (Print name): / Title:
Signature: / Telephone:
THIS SECTION IS FOR ADMIN USE ONLY / AQP / NON AQP
Date
Received / Urgent / Soon / Routine / Preferred Clinic / Doms/ Clinic / Checked by Podiatrist (Name) / Urgent/ Routine / Date
Triaged by: / Date:
AQP / NON AQP / CODE
Urgent/Routine / (Circle) Routine Nail Surgery Dom
Home
Comments:
Appt to be made at:
Date added to waiting list: / Labels Printed:
If existing patient, file required from:

Thank you for completing this form.

Please return to: Podiatry Dept, Single Point of Access, Waters Meeting Health Centre, Waters Meeting Road, Bolton BL1 8TU Tel. No. 01204 462626 Fax No. 01204 463023

Important notes for all patients and referrers

All patient referrals for Podiatry are primarily triaged at Head Office by a Senior Podiatrist. In order to do this accurately it is essential that we are made aware of the patient’s foot healthproblem, medical conditions and any medication that is taken. Please fill in the details on the form as comprehensively as you can. This form will be returned if incomplete.

Bolton Foundation Trust provides Podiatry Foot Health Services to those patients whose feet are most ‘at risk’ of serious problems. This means that not every patient who is assessed will be eligible for Podiatry treatment. The Podiatrist will assess the foot health needs of a patient within the guidance previously agreed with the Foundation Trust, General Practitioners and other Health Care Professionals. This will take into consideration the patient’s general health as well as their foot health.

The provision of foot health care is based strictly on clinical need. Able patients will be asked to undertake their own basic foot-care if it is considered safe to do so. Where self-help is not possible, carers will be encouraged to undertake this on the patient’s behalf.

Podiatrists may discharge patients in cases where foot health advice is ignored or where in their opinion the patient is no longer in need of our services.

Patients who fail to keep their appointments may also be discharged from the service.

Podiatrists do not routinely treat verrucae. This is in accordance with evidence to suggest that most lesions resolve naturally via an autoimmune response. However if you feel that referral is necessary this would be triaged by appropriately.

Finger nail cutting is not within the scope of practice of Podiatrists or Podiatry Assistants

We have a strict housebound criteria and patients must be housebound in order to be eligible for home visits.