Toe Nail Cutting Service – Application Form

PLEASE NOTE:owing to our strict safety and insurance policy please see page 2 of this application for more details about our restrictions.

This is not a free service and we are unable to make home visits.

Contact Information
Name (please include your title, e.g. Mr, Mrs, Miss, Ms, etc): / Date of Birth: / Present Age:
Address:Home Tel:
Mobile Tel:
Email:
Postcode:
Emergency Contact Details (Please give the name of someone we can contact in an emergency):
Name:Relationship to you:
Address:Telephone Number:
Postcode:
GP’s Name:
Address:
Tel:
Would you like us to contact you or someone else to discuss appointments?
 I would like you to contact me using the details I have given.
 I would like you to contact the following person to arrange all appointments.
Name:Relationship to you:
Address:Telephone Number:
Postcode:
How did you hear about our toenail cutting service?
G.P/Nurse Friend Poster/Flier 
Other (Please give brief details):
Have you used this service before /  Yes /  No

It is important that you complete this section as accurately as possible in order that we can assess your suitability for this service. Please ask your G.P for help if necessary.

Restrictions to our service–do any of the following apply? / Yes / No
Do you have Diabetes? (Insulin dependent, diet or tablet controlled)
Do you have Heamophilia?
Are you taking any Anti-Coagulant/Platelet drugs other than Aspirin?
(e.g. Warfarin, Clopidogrel, Rivaroxapan, Dypridamol, Xarelto)
Are you taking a long-term course of steroids?
(By long term we mean several months or longer)
If you have answered YES to any of the questions above then unfortunately we will not be able to offer you our toenail cutting service owing to our strict safety and insurance policy.
Please contact our office for a list of fully registered podiatrists in your area who may be able to offer you their service.
Health Information / Yes / No
Are you registered with the NHS podiatry service?
Are you Immunosuppressed? (Ability to fight infections is impaired. Can occur in transplant patients or those with HIV/AIDS)
Do you have any allergies? (eg; to latex, plasters, alcohol). Please give details:
Please list ALL medication that you are currently prescribed:
Do you suffer from any of the following: / Yes / No / If you have answered yes please provide brief details.
Corns
Bunions
Deformed, abnormal or
thickened toenails
Fungal infections (e.g. Athletes foot)
Hard skin
Ingrown toenails
Poor circulation of the feet (through ulcers, peripheral vascular disease, etc)
Please indicate below which clinics you would be willing/ able to attend. We do not make home visits. Please tick all that apply.
 Calne
 Chippenham
 Corsham /  Devizes
 Malmesbury
 Marlborough /  Melksham
 Trowbridge /  Warminster
 Westbury
Help with costs / Yes / No
I will have difficulty with the cost and would like someone to contact me to discuss what help is available
Are you happy for us to contact you about the following?
I would like to receive information about Age UK Wiltshire and its events, activities and campaigns by letter or newsletter
I would like to be involved with any consultations, surveys or questionnaires that may be relevant to me or my circumstances.

CONFIDENTIALITY, SERVICE USER CONSENT AND DATA PROTECTION

In order to provide this service, we need to keep recorded information. To ensure that we can meet the needs of people, Age UK Wiltshire is registered under the Data Protection Act 1998 for holding personal and / or sensitive information. If you do not wish us to hold any recorded information about you on our computer database and manual files it may not be possible for us to offer you this service.

Any information you have given us will be kept strictly confidential to Age UK Wiltshire. We will only discuss your personal details with a third party if we have your express permission to do so.

Please Note: However, in exceptional circumstances, which we are happy to discuss with you, we may have to disclose personal details.

You have the right to see any information written about you but we ask that you give us at least forty days notice if you wish to do so.

To the best of my knowledge the information given above is correct & if further details are needed to assess if I am suitable for the scheme I give permission for AUKW to contact my GP.

Signed:……………………………………………………Date:…………………………

Thank you for completing this form. Please return it to:

Age UK Wiltshire, Cromwell House, 31 Market Place, Devizes, SN10 1JG

Once we receive it you will be contacted by one of our team.

Age UK Wiltshire | Toenail Cutting Application FormPage 1 of 3