Camden Community Health Podiatry Referral Form

Camden Community Health Podiatry Referral Form. version 1.5 September 2013

This version of the referral form is for If you prefer to print and handwrite the referral, you entering information using Microsoft Word. can download that version from http://www.camdenproviderservices.nhs.uk/referrers Type in the grey boxes or choose from the and choose the podiatry referral form. drop-down lists as appropriate.

Information about the person being referred Title Forename Surname

Address

Home: Phone numbers Mobile: Other: Referral date NHS number Date of birth First language Is an interpreter required? Is the person housebound? Does the person have a learning disability? Does the person have any allergies? If yes, which? If the person being referred has a Carer’s name: carer, please supply the carer’s Contact phone number: details Relationship to the person being referred:

Monitoring information about the person being referred Ethnicity: Religion/faith: Gender: If other, which? If other, which? Sexual orientation: Does the person consider themselves (response for sexual orientation is not required if the person being referred is a child) to have a disability?

Why are we asking for this information? Camden Community Health podiatry is a service of Central and North West London NHS Foundation Trust (CNWL). The Trust has a legal responsibility to pay due regard to eliminating discrimination, advancing equality of opportunity and fostering good relations between people of different groups. To help us to do this, it is important we have a good understanding of how our services are received. With up-to-date and accurate information we are able to better:  Understand our service users and shape the Trust’s services to meet their specific needs.  Identify and tackle any issues different people may have when accessing services.  Ensure that people who need our services the most are able to access them. Your replies will not be used in a way that identifies you however they will help us to understand how community needs may vary. They help us make informed decisions on how we develop services and target resources.

Details of the GP of the person being referred GP name Name of the practice If the referral is being made by someone other than a GP, please supply your details Name of the person making the referral Organisation and address

Telephone

Information about the referral Please enter the category for this referral

Reason for this podiatry referral * *Nail cutting is not provided for people with low medical risk. Please see our eligibility criteria. Does the person have diabetes?

Medications list (or attach a separate sheet)

Medical history

Any other information you would like us to know

Please send the completed form by mail, fax or email to: Podiatry email: [email protected] Camden Community Health phone: 020 7685 5601 Peckwater Centre fax: 020 7485 5306 6 Peckwater Street London, NW5 2UP web: www.camdenproviderservices.nhs.uk/service/foot-care

Camden Community Health Podiatry referral form. Version 1.4. September 2013 Central and Northwest London NHS Foundation Trust Headquarters, Stephenson House, 75 Hampstead Road, London, NW1 2PL