Podiatry Services
Registration & Referral Form 

NHS podiatry treatment is available to those residents of South Manchester with a clinical need. 

The Podiatry Department provides a full and comprehensive range of services including.
 
•	Minor surgery for painful corns and nail conditions 

•	Foot ulcer assessment and management 

•	Biomechanical assessment of gait problems 

•	Prescription and manufacture of foot orthoses 

•	Assessment and management of children’s foot problems 

•	Foot health promotion and education 

•	Basic foot care training for carers 

Nail cutting and pedicures for healthy able-bodied persons are NOT available from the NHS. 

To request a podiatry appointment please complete all sections on both sides of this form 
Personal Details
Surname 
Surname 		Mr. 	Mrs. 	Miss 	Ms 	
Forenames 		Date of Birth			
Calling Name 		Date of Birth 			
Address 
Home Full Address (stacked) 					
				Postcode 
		
Telephone Number 
   Patient Home Telephone
   Patient Mobile Telephone 	NHS Number 	NHS Number 			

GP Details

GP Name
Referring User 	
Practice Address
Bodey Medical Centre, Ladybarn Court, 28 Ladybarn Lane, Fallowfield, Manchester, M14 6WP

Ethnic Background 
Ethnic Origin 	Tick 	Ethnic Origin 	Tick 	Ethnic Origin 	Tick 	Ethnic Origin 	Tick 	
Bangladeshi 		Chinese 		Irish 		Vietnamese 		
Black British 		East African Asian 		Middle Eastern 		White British 		
Other Black 		Other African 		Pakistani 		White Other 		
Caribbean 		Indian 		Somali 		Other 		
I do not wish to disclose my ethnic background 					

(This information helps us to make sure we are reaching all groups of people) 
Reason for Requesting Treatment Please tick the boxes below that best Describe your problem 
Is your GP treating you for the following medical conditions 	Tick 	Foot Problem Needing Treatment 	Tick 	How painful is your foot problem 	Tick 	
Diabetes 		Ulcers & Infection 		Constant pain 		
Circulation problems 		In growing toe nail 		Pain only when walking 		
Arthritis or Rheumatism 		Corns & Callous 		Occasional pain 		
Loss of feeling in feet 		Thickened nails 		Discomfort 		
Other 		Other 		No pain or discomfort 		

Please tick in the box to indicate your nearest local clinic 
Baguley Clinic 
Hall Lane 
Baguley M23 8NA		Burnage H.C. 
347 Burnage Lane 
Burnage M19 1EW		Northenden H.C.
489 Palatine Road Northenden M22 4DH		
Withington Clinic 
535 Wilmslow Road Withington M20 4BA		Forum Health
Simonsway
Wythenshawe M22 5RX		Brownley Green H.C.
Brownley Road
Benchill M22 4GA		
Withington Community Hosp
Nell Lane
West Didsbury M20 2LR		Treatment at home
(A very limited service is available to patients who are totally housebound and a mobility assessment will be undertaken		

All persons requesting an appointment will have their foot problem(s) assessed by a podiatrist. If treatment is required a treatment plan will be agreed with the patient before treatment commences. 

I confirm that the information given above is correct and I wish to receive a podiatry appointment 

Official use 

When you have completed all sections please return this form to the address of the clinic of your choice.