Self-referral Form

REFERRAL FORM INFORMATION

Please read all sections carefully before completing your referral form. If any sections are left blank you will not be offered an appointment and the referral form will be returned to you.

It is very important that we have a full picture of your medical condition including any medication you may be taking currently.

It may be necessary for us to contact your GP to obtain further information about your condition.

WHAT HAPPENS NEXT?

• Your referral is assessed against the criteria for eligibility to receive NHS Podiatry.
• Eligible patients are notified by post and asked to contact the booking centre to make an assessment appointment. If they do not contact the centre within 3 weeks of receiving this letter the referral is discharged.
• All non-eligible applicants will be notified as soon as possible by letter.

Podiatry Service Referral Criteria         

To be eligible for assessment or treatment the patient should fall into the high risk medical category with an associated risk to the limb or an acute/chronic podiatric need listed below.

PLEASE NOTE: Medical conditions listed should be showing signs or symptoms in the feet/legs and should constitute a risk to the integrity of the limb and/or limit mobility and function of the limb.

We cannot accept referrals for annual diabetic foot assessment, general footcare or nail care without a clearly indicated risk to the limb. We cannot accept referrals for minor foot conditions e.g. hard skin and corns, from applicants who do not fall into any of the Medical categories.

1. High Risk Medical Categories (must also be showing signs or symptoms in feet/legs)

• Diabetes with one or more of the following conditions; peripheral neuropathy, peripheral vascular disease or foot deformity, symptomatic skin and nail conditions
• Rheumatoid Arthritis or Connective Tissue Disorder with one or more of the following conditions; peripheral neuropathy, peripheral vascular disease or foot deformity, symptomatic skin and nail conditions
• Peripheral Vascular Disease (Impaired Blood Supply to Feet)
• Immuno-suppressed
• Neurological conditions directly affecting the feet
• Renal Problems requiring renal replacement therapy
• On ‘End of Life’ care pathway

This list is not exhaustive and may be updated or amended

1.Podiatric Needs

Acute Needs

• Infection
• Ulceration
• In-growing Toe Nail – where nail surgery is appropriate this will be the only treatment option, where nail surgery is not appropriate alternative self-care will be advised

Chronic Needs

• Symptomatic skin conditions in combination with any one of the High Risk Medical Categories. Note – Social nail care / fungal nails / verrucae are not accepted by the Podiatry Service.
• Biomechanical needs – Structural foot problems e.g. foot and ankle pain, associated knee / hip pain or congenital deformities.
• Paediatric foot and ankle development

All eligible patients will have an initial assessment, resulting in a treatment plan. The treatment plan is an agreement to accept, comply with and take shared ownership for their care. The treatment plan will be formulated with a view to resolution of the problem and discharge from the service, if appropriate. In cases of repeated non-compliance, a full review of the treatment plan will be undertaken which may result in the patient being discharged from podiatry service prematurely.