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Our vision: To improve the health and wellbeing of the people of Leicester, Leicestershire and Rutland by providing high quality, integrated physical and mental health care pathways.
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    IMPORTANT - we will ring you to book your appointment. If we cannot reach you, an appointment may be sent in the post or your application rejected

    Important - this is important as we will ring to contact you to arrange your appointment

    Important - we will ring to contact you to arrange your appointment

    Please indicate if it is ok to leave a message on your home answer machine or voicemail as appropriate.

    By supplying this we will assume we have your consent to contact you in this way

    Please include a telephone number











    Please ensure the patient is aware of and agrees with the referral and is able to accept an appointment within 2-3 weeks.





    Do you have any specific or special requirements / needs when being contacted, assessed or treated by Podiatry Services?

    Please explain the current problem you are having with your foot / feet




    Please indicate if you have any of the following

    If so, what are they? (e.g. High Blood Pressure, heart condition, communication difficulties, sever mobility problems, dementia etc) If not please write 'none'

    Please tell us what medicines you are taking or using; otherwise indicate by entering 'none'

    Such as redness, swelling, heat, pus, pain

    Do you have any known allergies e.g. Latex? please state or answer 'none'

    Have you had, or are you waiting for any operations or medical tests? if not please answer 'none'




    Confirmation

    You should get confirmation that your application has been submitted. If you dont, please check for errors on your application or missing *mandatory fields*.

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    Disability Confident Employer