Community Podiatry Self-Referral Form Please complete this form as fully as possible. Missing information will result in a delay to the processing of your self-referral. Please email completed forms to: dgft.podiatry.office@nhs.net Alternatively, you can post the completed form to: Self-Referrals, Podiatry, Brierley Hill Health and Social Care Centre, Venture Way, Brierley Hill, West Midlands, DY5 1RU If you need assistance completing the form, please call: 01384 321437

Details of self-referrer:

Date of Birth: Name and Address (including postcode):

Gender:

Ethnicity:

Telephone Number:

Email Address:

How would you prefer us to Contact you?

NHS Number (if known):

Next of Kin: Contact Number:

GP Name:

GP Contact Number: GP Address:

Interpreter Required? If yes, which language is required?

Excluded From Our Service:

Patients who have existing foot care provision Patients who manage their own foot care	Fungal Nail Infection	Verrucae	Nail care	Non-painful Corns or Callus Annual Diabetic Foot Checks Please do not make a self-referral for any of the following:

Please see list below for alternative services**

Reason for Self-Referral: Give a brief description of your problem including how it started: Area of pain / How it started /Any previous treatments?

How long have you had this problem?

Is your problem?

Please give details: Have you had any investigations for this problem? (E.g. Scans, X-rays, Blood tests, etc)

General Health – Please tick if you have any of the following:

Please give details if yes to any of the above:

Since the onset of this problem do any of the following apply to you?

Areas of the foot which are red/swollen/hot/inflammation

Open wounds on the foot (especially if you are diabetic)

Foot ulcer

Feet which are cold/dusky/painful

Night cramps or cramps when walking a short distance in legs

Mobility – do you have any issues with mobility?

If Yes, please give details on your mobility issues:

**Patients who are not for NHS services can use the following:

Age UK

Age UK Stepping Out Service at Cross Street Practice, Dudley:

T: 07702 568 857 (Direct) 0121 437 0033 (General) 0121 437 0479 (Information & Advice)

E: info@ageukbbc.org.uk

W: www.ageukbbc.org.uk

Birmingham Nail Care Service

http://www.bhamnailcare.co.uk/

Covering: Cradley health, Halesowen, Quinton, Coseley, Sedgley and Stourbridge.

Private Podiatry /Chiropody

Click on Feet for Life web site www.feetforlife.org where you will be able to search for your nearest Private Podiatrist. To check if the Podiatrist you have chosen is registered with the Health Professions Council please search on www.hpc-uk.org

PODIATRY DEPARTMENT USE ONLY
Date Referral Received: Referral:
Triaged Criteria:
Caseload:
Triaged by:	Date:
Patient Mobility ( Please tick relevant box)
Personal:
Transport:

Version 1.1 - 05/05/2021