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Home - Services - Podiatry - Podiatry Referrals

Podiatry Referrals

HDFT Podiatry Referral Form

Criteria for Referral for Podiatry Assessment/Treatment

Do you meet the criteria for receiving Podiatry treatment?

Category 1	Category 2	Category 3
Foot (podiatric) medical need Ulceration / non-healing foot wounds Foot infection requiring antibiotics (excludes fungal nails) In-growing toenail with inflammation / infection Painful corns Painful, large areas of callus	Neuropathy (e.g. diabetic loss of sensation) Peripheral Arterial Disease (very poor circulation) Rheumatoid / inflammatory arthritis Diabetes – moderate or high foot-risk classification Neurological disorders (e.g. MS) Currently undergoing chemotherapy On dialysis Non-traumatic foot / leg amputation	General nail care Minimal or non-painful callus or corns Fungal skin infections Verrucae or warts Diabetes – low foot-risk classification (annual checks via your GP practice) Foot deformity (e.g. bunions, flat feet) not causing pain

If you meet any of the criteria in Category 1 or Category 2, you will be offered a primary assessment appointment. After this assessment you may receive:
– Advice (and discharge to continue self-care), or
– A block of treatment to meet your foot-health needs.

If your condition falls within Category 3, NHS podiatry treatment cannot be provided.

If you have a foot problem but do not meet the criteria for NHS podiatry care, you can use the self-care guidance on our website:
https://hdft.nhs.uk/services/podiatry/

If you don’t feel able to self-care, we recommend you see an HCPC-registered private podiatrist.

If you believe you meet the criteria for NHS podiatry treatment, please continue to complete the podiatry referral form.

Podiatry Referral Form - Please Select(Required)
- Professional Referral
- Self-Referral
Patient information
Full Name(Required)
Date of Birth (DD/MM/YYYY)(Required)
NHS Number (if known)
Address(Required)
Contact Number(Required)
Email(Required)
G.P information
G.P Name
G.P Address(Required)
G.P Contact Number(Required)
G.P Email
Medical Details
Medical History(Required)
- Diabetes
- Active Foot Ulcer
- Connective Tissue Disorder
- Gout
- Heart Attack/Stroke /Angina
- Hypertension
- Loss of feeling in toes /feet
- Neurological conditions
- Previous Amputation
- Renal Impairment
- Rheumatoid /Inflammatory Arthritis
- Other
Other please specify
Recent HbA1c if known
Risk level if known
Allergies(Required)
- Yes
- No
Please specify allergies
Medication(Required)
Please write none if you take no medications
Reason for referral (please select one or more)(Required)
- Foot wound
- Infected/Painful Ingrowing Toe Nails
- MSK problems
- Painful Callus
- Painful Corns
- Red hot swollen joints/soft tissue area
- Other please specify
Please provide more detail of your current foot care needs and problems
Please indicate current level of pain in your feet(Required)
- 0 - None
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - Extreme
Is this a new problem?(Required)
- Yes
- No – this is a flare up of a previous problem
- No – this is a long standing condition
History of any recent Foot and Ankle Injury(Required)
- No
- Yes
Please describe below
Please describe impact of pain on day to day activities(Required)
Have you had any previous NHS treatment(Required)
- Yes
- No
Please attach a photo of your foot problem
Drop files here or

Accepted file types: jpg, png, jpeg, Max. file size: 10 MB, Max. files: 10.
Mobility Assessment
A very limited service is available to patients who are totally housebound. Patients eligible for a home visit by the podiatry service are those who are one or more of the following:
- Persons who are completely bedbound
- Persons who require hoisting in order to be moved or to travel
- Persons who would become ill if required to travel to a clinic
- Persons deemed on a temporary basis to be clinically too ill to be reasonably expected to travel
We may contact yourself or your carer for further information regarding this.
Are you housebound?(Required)
- Yes
- No
Mobility Assessment
I require a home visit because (please tick all that apply):
- I am bedbound
- I use a hoist and am unable to travel in a wheelchair taxi
- I am too ill to be expected to travel to clinic
Interpretor required?(Required)
- No
- Yes
Please specify language
Referrer Information
Referrers Full Name (print)
Relationship to patient
Date (DD/MM/YYYY)
Referrers Contact Number
Privacy Policy(Required)
I can confirm that I have read, understood and accept the privacy policy.
I agree to the privacy policy.

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