Lambeth and Southwark Community Foot Health Services Referral Form

Lambeth and Southwark Community Foot Health Services referral form It is important that all fields are completed as missing information may cause a delay. Forms should be returned via ERS or can be emailed to: Email: [email protected] Address: Artesian Building, 94 Alscot Road, Bermondsey, SE1 3GG Tel: 0203 049 7900 (option 2) IMPORTANT: If you are housebound and unable to attend a clinic please ask your GP or other healthcare professional to refer you using this form via the above email or post address. Referrer details Please complete this section if you are referring somebody other than yourself Name Organisation Address Post code Contact number Is the person you are referring housebound? Y / N

Patient details Title (Mr/Mrs/Miss) First name Last name Date of birth / / Address Post code Home Tel number Mobile Tel number Email address if you would like to be contact via this method NHS Number Interpreter If yes, which Y / N if known required language

General Practitioner details GP Name Dr Practice Address Post code Contact number

General Health If you have no medical problems please tick this box  otherwise review below and tick if you have been diagnosed with; Yes No Yes No Diabetes Liver/kidney problems Leg/foot circulation problems Arthritis Neurological problems Learning disabilities Heart problems Dementia Chest/breathing problems Any additional information

Details of any operations Any known allergies

Medication Please tick here if you take no medication  otherwise please list any medication you take, to include tablets, creams and inhalers. You can attach a prescription sheet if easier.

Foot problem Please give further information on why you are requesting a foot health assessment including how long you have had the problem.

Please select a preferred clinic from the list below (some specialist services are only available at certain clinics, you will be advised if appropriate) Clinic name Address Tick Akerman Health Centre 60 Patmos Road, Brixton, SW9 6AF Artesian Podiatry Centre Artesian Building, 94 Alscot Road, Bermondsey, SE1 3GG Clapham Manor 86 Clapham Manor St, Clapham, SW4 6EB Elmcourt Health Centre 214-218 Norwood Road, Norwood, SE27 9AW Gaumont Surgery 153 Peckham High St, Peckham, SE15 5SL Gracefield Gardens 2-8 Gracefield Gardens, Streatham, SW16 2ST Lambeth Community Care Centre Monkton Street, Kennington, SE11 4TX Mawbey Brough Health Centre 39 Wilcox Close, Vauxhall, SW8 2UD Townley Road Clinic 221 Townley Road, East Dulwich, SE22 8SW

Community Foot Health patient information

What happens next?  Your referral form will be reviewed by a podiatrist. It is therefore important that you provide as much information so we select the correct clinic for you.  Our Referral Management Centre will contact you by telephone/email within two weeks (and by post if we are unsuccessful in contacting you) to agree a clinic location, date and time suitable to you.  If you do not hear from us within this time please call on 0207 188 9910, Monday to Friday 9am to 3.45pm. At your assessment appointment  You will be assessed by a podiatrist who will discuss the significance of your foot problem with you and if appropriate, treatment will be started.  You may need an episode of podiatry care and the number and frequency of the appointments will be agreed with you.  You may need an episode of podiatry care with a specialist podiatrist following your first appointment. This will be arranged with you but please note it may not be at the closest clinic location to you.  You many need advice on how you can manage a foot health problem effectively yourself and therefore will not require further appointments.  We will provide verbal and written information to you at your appointment and there will be time for any questions you may have.

Emergency clinics We provide emergency clinics if you think that your foot problem is urgent . Examples of this are bleeding, swelling and infection.

Please see clinic location list and times below where the podiatrist will provide assessment, advice and treatment if appropriate. Clinics can become busy so please be prepared to wait. Complete this form and take it to the reception desk at your preferred location.

Day Time Clinic Address Telephone 153 Peckham High St Monday 1:30pm -3:40pm Gaumont Surgery Peckham SE15 5SL 86 Clapham Manor St Monday 1:30pm -3:40pm Manor Health Centre Clapham SW4 6EB 2-8 Gracefield Gardens Tuesday 1:30pm -3:40pm Gracefield Gardens Streatham SW16 2ST 214-218 Norwood Road Wednesday 9:50am -12:30pm Elmcourt Norwood SE27 9AW Artesian Building Podiatry Centre 0203 049 7900 Wednesday 1:30pm -3:40pm 94 Alscot Road Artesian Bermondsey SE1 3GG Mawbey Brough Health 39 Wilcox Close Thursday 1:30pm -3:40pm Centre Vauxhall SW8 2UD Mawbey Brough Health 39 Wilcox Close Friday 1:30pm -3:40pm Centre Vauxhall SW8 2UD Artesian Building Podiatry Centre Friday 1:30pm -3:40pm 94 Alscot Road Artesian Bermondsey SE1 3GG Helping us to understand more about the patients and the community we serve Guy’s and St Thomas’ is committed to diversity and equal opportunities for all. Collecting this information enables us to have a better picture of any particular needs of our diverse patient community. This information is to help us monitor the effectiveness of our equality and diversity policies and to help comply with legal requirements.

1. Who is the main person answering the questions below? □Patient □Carer/family member □ Both patient and carer together □Other

2. Have you ever visited the Podiatry department before? □Yes □ No

3. Are you? □Male □Female □ Prefer not to say

4. What age group are you? □Replying on behalf □18-24 □25-34 □35-44 □ 45-54 of a child under 16

□55-64 □65-74 □75-84 □ 85+ □Prefer not to say

5. What is your sexual orientation? □Bisexual □Gay man □ Gay woman/lesbian □Heterosexual/straight □Other □ Prefer not to say

6. What would you consider to be your ethnic background? □ White British □White □Any other □Indian □Pakistani □Bangladeshi Irish white background □Any other □Black □Black African □Any other □Chinese □White and Black Caribbean Asian Black Caribbean background background □ White and □White and □Any other □Other □Prefer not to say Black African Asian mixed background

7. What is your religion? □ Buddhist □ Christian □Hindu □Jewish □Muslim □ Sikh □Other □ No religion □ Prefer not to say

Thank you for your time!

Data protection statement Thank you for taking the time to complete our survey. The information you have provided will be treated confidentially. The comments that we have received will not be attributed to any individuals. This information is also used by the Foundation Trust to help us monitor the effectiveness of our equality policies and to help comply with legal requirements.