<p>Podiatry Application Form</p><p>Complete all sections in ink and use block capitals. If all sections are not completed, there may be a delay in processing the application.</p><p>Personal Details</p><p>Title Forename (s)</p><p>Surname Known as (or preferred name if different Date of birth NHS number</p><p>Address (including post code)</p><p>Telephone Mobile number number</p><p>Name of Surgery address registered doctor</p><p>Emergency Relationship contact name / next of kin Telephone Mobile number number</p><p>Has NHS Podiatry been provided in the last year? Please tick NO□ YES□ If yes, please specify location……………………...... </p><p>For administration use only Date Triage: Action: Print name: received: Urgent □ Not eligible, not in priority group, Routine □ discharge □ Accepted, added to waiting list □ Accepted, send out opt in letter □ Date: Accepted, urgent telephone contact needed □ Return form to sender as more info needed □ Reason for referral to the podiatrist</p><p>Please tick the boxes that describe what affects the foot at present: Ulceration Loss of sensation</p><p>In growing toe nail +/- infection Dry cracked skin</p><p>Foot infection requiring medication Corns and / or callous from the GP Foot / lower limb pain Thickened nail</p><p>Biomechanical (gait) problems Fungal nail</p><p>Please provide a brief description of presenting foot complaint:</p><p>Medical history</p><p>Please tick the boxes that apply: Type 1 Diabetes (risk assessed Immuno increased, high or ulcerated in line with NICE -suppression/deficiency CG10) Type 2 Diabetes (as Type 1) Heart disease</p><p>Peripheral Vascular Disease Stroke</p><p>Chronic severe oedema including Renal disease lymph oedema</p><p>Neurological disorder Connective tissue disorder e.g scleroderma, hypermobility Rheumatoid Arthritis Other please state:</p><p>Please list all prescribed medication:</p><p>Referrers Referrers Name Designation Signature Date</p><p>Please send referrals to Podiatry Service, Victoria House, Park Street, Hull, HU2 8TD</p>