North Podiatry Services Referral Form

Office use only Indicate Triage Outcome Choice of clinic for appt Triage Date Triaged by AQP Routine AQP Bio AQP Urgent AN CTR CH CL CS Non AQP Dom Non AQP High Non AQP Urgent HH HOP NH PH Risk Please complete all sections on both sides of the form or the referral will not be accepted.

Surname Mr Mrs Miss Ms Date of Forename(s) Birth Address

Post Code Telephone NHS Mobile Home Number First Does the patient Langauge Language need an interpreter? Y Required / N GP Name

GP Practice Address

Please list your medical history and a full list of your medication.

Please list full details of your foot problem.

Podiatry assessment involves the development of a treatment plan which may include treatment, self management, advice and discharge. Please indicate 3 clinics which you are able to attend for an appointment. Charlestown Clayton Cornerstones Cheetham Hill Plant Hill Higher Home treatments are only available to those who are completely housebound.

If an assessment is required for this please tick this box. Please Turn Over 

Please complete all sections on both sides of the form or the referral will not be accepted. Incomplete forms will be returned to the referrer

North Manchester Podiatry Services Referral Form

Equality and Diversity (This information helps us to make sure we are reaching all groups of people)

Ethnic Background Bangladeshi Chinese Irish Vietnamese Black British East African Middle Eastern White British Asian Other Black Other African Pakistani White Other Caribbean Indian Somali Other I do not wish to disclose my ethnic backbround Religion Christianity Buddhism Judaism None Sikhism Islam Other I do not wish to disclose my religion Sexual Orientation Heterosexual / Straight Bisexual Lesbian / Gay Man / Gay Woman I do not wish to disclose my sexual orientation

NHS Podiatry services are only for patients with relevant medical and podiatric needs.

Pennine Acute Hospitals NHS Trust is a teaching organisation and it is possible that your treatment may be undertaken by students.

Please complete all sections on both sides of the form or the referral will not be accepted.

Incomplete forms will be return to the referrer.

I confirm that the information given above is correct and I wish to receive a podiatry appointment.

Siganture of applicant or referrer Date

Completed forms should be sent to:

Podiatry Department Harpurhey Health Centre 1 Church Lane Harpurhey Manchester M9 4BE

Tel: (0161) 861 2400 Fax: (0161) 205 5860

Please complete all sections on both sides of the form or the referral will not be accepted. Incomplete forms will be returned to the referrer