Single Point of Access Application for Podiatry (Chiropody) Form (Version SN/SB April 2013)

New patients should expect to receive their first treatment within 18 weeks of the referral being received. NHS Podiatry is provided on the basis of clinical need and referrals are prioritised. You may be discharged if you do not fulfil the acceptance criteria. Please tick below any boxes that apply;

List current health/foot problems (you may tick more than one box); [ ] Circulatory disorders [ ] Diabetes [ ] Infection [ ] Wound care [ ] Immunocompromised status [ ] Neurological problems [ ] Rheumatoid arthritis [ ] Nail surgery [ ] Long-term conditions [ ] Foot pain [ ] Biomechanical problems requiring advice, insoles or orthotics [ ] Corns, callus and other skin lesions [ ] Thickened or deformed nails [ ] Other ………………………………………………

LOW PRIORITY e.g. basic foot care due to minor foot problems, poor eyesight; [ ]

Reason for referral (describe the foot problem(s) and/or medical condition, please note a basic nail- cutting service is not provided):

Urgent Referral Y [ ] N [ ] Falls (this must be completed): Number of falls in last year [ ] Number of near falls in last year [ ] Do you have a fear of falling? Yes [ ] No [ ] Medication (detail regular medication here or bring a list with you to your first appointment):

Height: Weight: Shoe size:

Surname: …...……………………..… First Name: ………………………………… Title: ………….………..

Address: ..……………………………………………………………………………………………………….…...

Post Code: ………………………… Date of Birth: …………………… NHS No: ……………………..……..

Telephone: ………………………… Mobile: …………………………… Email: …………………….………..

GP: …....…………….………….……… GP Practice: ….…………...……………………………………………

Ethnicity (tick as appropriate): [ ] White British [ ] White Irish [ ] Any Other White Background [ ] Mixed, White & Black Caribbean [ ] Mixed, White & Black African [ ] Mixed, White & Asian [ ] Any other Mixed Background [ ] Asian or Asian British, Indian [ ] Asian or Asian British, Pakistani [ ] Asian or Asian British, Bangladeshi [ ] Any other Asian Background [ ] Black or Black British, Caribbean [ ] Black or Black British, African [ ] Any other Black Background [ ] Other Ethnic Groups, Chinese [ ] Any other Ethnic Group [ ] Not Stated

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Gait problems, postural foot problems, foot deformity, - requiring insoles/orthotics/advice [ ] Biomechanics/Podopaediatrics (East) – Biomechanics Centre 1 Walker Close IP3 8LY [ ] Biomechanics/Podopaediatrics (West) - Newmarket Community Hospital CB8 7JG

For patients requiring nail surgery (urgent cases can be faxed to Podiatry Office) [ ] Nail Surgery (East) – Ravenswood Health Centre Ipswich [ ] Nail Surgery (West) - Newmarket Community Hospital

For other patients requiring general podiatry treatment for location please tick box; [ ] Community Hospital - IP15 5ES [ ] Botesdale Health Centre - GP Surgery IP22 1DW [ ] Brandon - Orbit Housing - Warren Close IP27 0EE [ ] - Blomfield House - Looms Lane IP33 1HE [ ] Eye - Hartismere Hospital - Castleton Way IP23 7DD [ ] Community Hospital - Constable Road IP11 7LT [ ] Hadleigh Health Centre - Market Place IP7 5DN [ ] Haverhill Health Centre - Camps Road CB9 8HF [ ] Ipswich - Allington Clinic - Woodbridge Road IP4 4ER [ ] Ipswich - Chantry Clinic - Hawthorne Drive IP2 0QY [ ] Ipswich - Ravenswood Health Centre - Henning Avenue IP3 9QJ [ ] Ipswich - Whitton Clinic - Meredith Road IP1 6ED [ ] Lakenheath Surgery - GP Surgery - High Street IP27 9EP [ ] Mildenhall Clinic - Chestnut Close IP26 7NL [ ] Newmarket Community Hospital - Exning Road CB8 7JG [ ] Clinic - Street Farm Road IP17 1AL [ ] Stanton Health Centre -The Chase IP31 2XA [ ] - Violet Hill Road IP14 INL [ ] Sudbury Health Clinic - Acton Road CO10 6QN [ ] Thetford Healthy Living Centre - Croxton Road IP24 1JD [ ] Wickhambrook Health Centre - GP Surgery - Boyden Close CB8 8XU [ ] Woolpit Health Centre - GP Surgery - Heath Road IP30 9QU [ ] Woodbridge - Framfield Medical Centre - Ipswich Road IP12 4FD [ ] Home visit – ONLY available to patients who are HOUSEBOUND

Referrer source: [ ] Patient [ ] GP [ ] Practice Nurse [ ] District Nurse [ ] Health Visitor [ ] AHP

[ ] Podiatrist [ ] Consultant [ ] Other Please specify: …………………..………….……………………………...

Referrer signature: ………..………………. Name (print): ……………………...…………….… Date: …………………

Emergency nail surgery referrals - Fax direct to Podiatry Office Allington House - Fax 01473 275 224

Send this form to: Yvonne Godden (Single Access Podiatry Referrals) Podiatry Office Allington House 427 Woodbridge Road Ipswich IP4 4ER Tel. 01473 275257 Fax. 01473 275224 Please note that failure to attend an appointment without notification or repeated consecutive cancellations may result in discharge from the service. A further appointment would then require a new referral. The service may send appointment details/reminders by SMS Text. For further information please contact Podiatry Office 01473 275204/280 or view the public website for the service which is: http://www.suffolk.nhs.uk/Home/Services/SuffolkPodiatry/tabid/600/Default.aspx