Patient Self-Referral to Podiatry Services

We provide services for patients registered with a GP in Haringey or Islington only. If you are registered with a GP outside of these boroughs we will not be able to accept your referral.

A self referral can be made using the form below, if the patient is aged 18 or above.

The service only sees people with medical conditions that put their foot health at risk, for example, uncontrolled diabetes.

Toenail cutting is part of personal care, so you may cut them yourself or someone else may cut them for you if you cannot. Toenails can also be cut by private Podiatry, Chiropody, Foot Health Practitioners, Beauty Therapists and Nail Salons.

We do not offer treatment for the following conditions:

Verruca
Corns and Calluses
Fungal Nail Infections
Basic Nail Cutting

Referrals for the above will be rejected.

Please ensure all the fields marked* are filled in correctly.

I confirm that I am happy to receive information by* !

Mobile

Please provide details* !

Patient details

Surname* !

First name* !

Gender* !

Female

Male

Date of Birth*(dd/mm/yyyy) !

Home Address and Postcode* ! !

Daytime number* !

Mobile number* !

NHS No.(if known)

Hospital No

Is an interpreter required?* !

Yes

How would you describe your ethnic origin* !

Next of kin* !

Home Address and Postcode* ! !

Telephone number*

GP details

GP Practice* !

GP Name

GP Address* ! !

GP Telephone number

Have you consulted your GP about this problem?* !

Yes

If Yes, what did they recommend

Give a brief description of your problem including how it started.(please only refer for one condition)*

Area of pain / How it started /Any previous treatments?

How long have you had this problem?* !

Less than 2 weeks

2 – 6 weeks

More than 6 weeks

More than 1 year

Is your problem?* !

Getting better

Getting worse

Staying the same

Have you had any investigations for this problem? (E.g. Scans, X-rays, Blood tests)* !

Yes

If Yes, please give details:

General Health

You must have a health condition that puts your foot health at risk in order to be accepted to our service. If you do not have a health condition listed below, it is likely that your referral will be rejected.

If this section is not completed, referral will be rejected.

Please tick if you have any of the following:

Lung Problems

Heart Problems

Epilepsy

Osteoarthritis

Rheumatoid Arthritis

Osteoporosis

Diabetes

Surgery / Operations

Previous Foot/toe or leg Fractures

Other significant Health Condition

If Yes to any, please give details

SINCE THE ONSET OF THIS PROBLEM Do any of the following apply to you? If you have the symptoms please tick

Areas of the foot which are red/swollen/hot/inflammation

Open wounds on the foot (especially if you are diabetic)

Foot ulcer

Feet which are cold/dusky/painful

Night cramps or cramps when walking a short distance in legs

If you have ticked any of these symptoms, and you HAVE NOT seen a doctor for this symptom, it is essential you arrange an appointment with your GP

DO NOT SEND IN THIS FORM UNTIL YOU HAVE SOUGHT FURTHER ADVICE

Please list any Medicine you are taking (leave blank if not on medication)

Employment status* !

Please give details

Any activities you do (E.g. Sports, Gym, Hobbies). Please give details:*

Due to your current problem you are unable to:

Work

Participate in activity/sport

Care for dependent

Other

Please give details

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