Community podiatry self referral form

How do I apply

To self refer complete the form below and if possible email a photo of your foot to [email protected]. Please include as much information as possible so we can prioritise your referral and book an appropriate appointment (face to face or telephone).

This service is available for anyone registered with a GP in Middlesbrough, Redcar and Cleveland.

Please note, we do not treat warts and verruca, fungal nails or normal nails.

Urgent diabetic foot problems?

If you have diabetes and any of the following: foot ulceration, open wounds, bleeding/pus, red/hot/swollen infected foot, and foreign body injuries and do not have an appointment with the diabetic foot team, please do not complete this form, make an appointment directly with the foot protection team:

Tel: 01642 854231
Email [email protected]

Podiatry self referral form

Name(Required)

Prefix First Last

Date of birth(Required)

NHS number(Required)

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Interpreter required?

If yes please state language

GP name(Required)

GP practice name and address(Required)

General health(Required)

Please list any medical conditions or surgical procedures

Current medication(Required)

Known allergies

Date self referral form completed(Required)

Why you are referring yourself(Required)

Please describe which areas of each foot are causing you pain or discomfort(Required)

Pain score(Required)

Please enter a number from 0 to 10.

(0=no pain, 10=severe pain)

Referral reason(Required)

Nail removal (all or part) under local anaesthetic

Treatment of painful corns and callus

Biomechanical assessment (joint or muscle pain)

Non healing wound to foot.

Foot pain

Foot deformity

Re issue of existing orthoses / insoles

Monitoring of diabetic foot (You must advise of your foot risk status following your last diabetic annual review, you may need to ask your GP for this information)

Please tick the relevant box then use the space below to give as much detail as possible, for example duration of symptoms and any treatment already received

More details(Required)

Your appointment

If a face-to-face appointment is required, you will be offered an appointment at the closest venue to your home address that provides the care you need. Our community clinics are open from 8.30am until 4.30pm. Podiatry is a clinic-based service, often involving sharp and specialist equipment. In a clinic setting, safe and effective treatment can be provided. Therefore, home visits are limited to those who are bedbound. Patients who do not meet these criteria, including those who use wheelchairs or walking aids will be asked to attend clinic. We will do our best to enable you to access a ground floor clinic, with accessible parking where required and provide sufficient notice to make transport or support arrangements.

We are aware that many people need footcare either because they are unable to do it for themselves or because they have become anxious about injuring themselves if they do. The podiatry service does not offer a general footcare or nail cutting service. Often a family member or other trusted person can manage your feet with care, but some people may still prefer for a professional to provide the treatment. When looking for the services of a podiatrist, their registration status can be checked using the Health and Care Professions Council (HCPC) website. Please be aware that other foot care professionals also exist, although legally they cannot refer to themselves as a chiropodist or podiatrist, so may present under different titles.

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How do I apply

Urgent diabetic foot problems?

Podiatry self referral form

Your appointment

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