The Leaf Hospital :: Self Referral Form

Self Referral Form

Title *
Name *
Surname *
Address *
Postcode *
Email Address *
Would you prefer correspondence to be sent by post or email? *	Post Email
Date of Birth *
Daytime contact number *
Emergency Contact Name *
Emergency Contact daytime phone number *
Emergency Contact Adress and Postcode *
Name of GP *
Address and Postcode of GP *
GP Phone number *
Please Describe your current problem [e.g. pain in heel of right foot] *
Since when have you had this problem? *
Is your problem painful? *	Yes No
If yes, is it:	Mild Moderate Severe
Are there any signs of: *	Redness Weeping Swelling Heat Bleeding None of the above
Have you received any medical treatment for this problem? *	Yes No
If so please give details
Are you currently taking any medication *	Yes No
If yes, please list all tablets and medicines that you take (check your repeat prescription)
Do you have any known allergies? (e.g. Penicillin, latex, anaesthetic, cat/dog hair, hay fever etc) *
Have you seen a Podiatrist or Chiropodist in the last 2 years? *	Yes No
If Yes, where did you receive this treatment?
Do you have, or have you ever suffered from any of the following?	Diabetes Circulation problems (e.g. Raynauds) Immunosuppression (e.g. renal problems) Rheumatoid Arthritis Osteoarthritis Stroke Heart problems Physical Disabilities Registered Blind or partially sighted Special Educational Needs Congenital Problems Neurological issues (e.g. multiple sclerosis) Terminal Illness Dementia
Other ailments not listed [please state]
Who Currently cares for your feet? *	Self Relative Partner Other
I consent to treatment and confirm the information given in this form is correct and agree to pay due charges for consumables. *	Agree

Consent of Treatment and Data Processing.

by submitting this form you agree and understand the use and purpose of the data as described in our privacy notice