Wirral GPCC & Wirral Alliance

Wirral GPCC & Wirral Alliance

AQP Community Podiatry Referral Form

(Wirral GPCC & Wirral Alliance)

Please fax/email completed referral form to the AQP Podiatry Provider selected. Please see contact details below:

AQP Podiatry Provider / Fax Number / Email Address / Contact Telephone Number
Peninsula Health / 01298 752 859 / / 0300 500 0390 (Option 3)
Wirral Community NHS Trust / 0151 488 3701 / / For GP Practice Team: 0151 514 2314 (Specific Queries/Requests for Information)
For Patients: 0151 514 2222 (Appointment Queries/Changes to appointments)
Patient Details:
Title: Mr Mrs Miss Ms
Other: ………………………..
Surname:
Forenames: / NHS number:
DOB:
Age:
Permanent Address
Post code:
Telephone: / Current Address (if different)
Post code:
Telephone:
GP details
Name:
Surgery: / Ethnic Origin
Please indicate whether the patient wishes to receive appointment reminders by text
Referral Information:
Routine Referral (patient to be seen within a maximum of 4 weeks)
Urgent Referral (patient to be seen within a maximum of 2 weeks)
Referrals that are considered to be urgent are (please tick as appropriate):
 Patients who present with pre-ulcerated changes
 Ulcerated feet (non-diabetics)
 Patients with connective tissue disorders associated with vasculitis
 High risk diabetic patients, without active ulceration
 Other (Please State)______
Patients presenting with diabetes related foot ulceration must be referred to WUTH diabetes foot clinic within 24 hours.
Please complete the Diabetes Foot Ulcer Referral Form loaded onto your clinical system
Domiciliary Visit:
Domiciliary Visit Required for Housebound Patient*
*Please see supplementary page of explanation for housebound criteria
Presenting Foot Complaint/Reason for Referral (see supplementary page of explanation):
 Treatment of Skin and Nail Conditions
 Nail Surgery Assessment
 Podiatric Assessment and Treatment of Diabetes
  • Previous Foot Ulceration

  • Previous Podiatric Intervention
  • Change in risk category
  • (Please state ‘At Risk’/’High Risk’)______

 Simple Wound Treatment
 Specialist Wound Treatment
 Treatment of ‘High Risk’ Foot (non-diabetes)
 Foot Orthoses
 Other (Please State)______
Diabetes Mellitus:
Diabetes Mellitus? / If yes, what type? Type 1 Type 2
Date of last annual diabetes foot check ______
Peripheral Vascular Disease:
Peripheral Vascular Disease / Warfarin?
Other Relevant Information:
Allergies:
Current Relevant Medication:
Other Supporting Information:
Referrer Details (GP Practice Team)
Name Print………………………………………….Signature………………………………
Designation…………………………………………………………………………………….
Date of Referral…………………………………….Contact Number…………………….. / Practice Address:

Supplementary Page of Explanation

The following providers have been awarded the contract to deliver the AQP for Community Podiatry:

Peninsula Health / Wirral Community NHS Trust
Service Base / Peninsula Health LLP, Birkenhead Medical Building, 2nd Floor , 31 Laird Street, Birkenhead, CH41 8DB / Podiatry Administration, The White House, 3 Port Causeway, Bromborough, CH62 4NH
Tier 1 - Core Podiatry to Ambulant Patients /  / 
Tier 1 - Core Podiatry to Non-ambulant Patients /  / 
Tier 2 - Specialist Podiatry to Ambulant Patients /  / 
Tier 2 - Specialist Podiatry to Non-ambulant Patients /  / 
Orthotics to Ambulant Patients /  / 
Orthotics to Non-ambulant Patients /  / 

 - denotes the provider can deliver the element of the AQP referred to

 - denotes the provider cannot deliver the element of the AQP referred to

Please note that the service will accept referrals for the following:

Treatment of Skin and Nail Conditions of the Foot:
  • Corns
  • Callus and hard skin
  • Verrucae
  • Thickened or ingrown nails
  • Fungal conditions of the feet and nails
  • Other dermatological conditions
  • Long Term conditions where the risk of foot ulceration and infection is low
  • Structural and functional abnormalities
  • Patients requiring personal foot care (defined as toenail cutting and skin care) that are incapable of carrying out as part of their everyday personal hygiene.

Diabetes Assessment and Treatment
Rheumatoid Arthritis Assessment and Treatment
Nail Surgery
Simple Wound Management (e.g. wounds not associated with diabetes, rheumatoid arthritis, peripheral vascular disease or any other long term condition)
Treatment of High Risk Foot (non-diabetes) such as:
  • Peripheral vascular disease
  • Systemic musculo-skeletal disorders
  • Immune mediated connective tissue disorders (including rheumatoid arthritis)

Specialist Wound Management (e.g. Management of foot ulceration (non-diabetic)
Foot Orthoses - assessment, measurement, fitting and review for patients identified as requiring foot orthoses (off-the-shelve insoles or custom-made insoles)
Criteria for Housebound:
  • Those who are so elderly and frail or infirm that it prevents them leaving the house
  • Those with severe physical disability that it prevents them leaving the house
  • Those with mental health problems which make it difficult to leave the home
  • Those with sensory disabilities especially severe visual impairment which make it difficult to leave the home
  • Those with profound or severe learning difficulties which make it difficult to leave the home
  • Those who are temporarily housebound e.g. post-surgery

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