About the patient Title Mr Mrs Miss Ms Other First name/names Required Surname/ family name Required Known as (or preferred name, if different) NHS number (if known) Date of birth Required Contact details Please make sure the contact details are accurate as we'll be relying on these to get in touch with the patient about their appointment or to find out more information. Home address Address 1 Address 2 City State/Province Country United Kingdom Postal Code Telephone number Mobile number Email Address Required I consent to receive mobile text appointment reminders Yes No I consent for messages to be left on my home phone Yes No I consent for messages to be left on my mobile phone Yes No I consent for you to view my Summary Care Record Required Yes No I need an interpreter Yes No I consent to share my electronic records Required Yes No Reason for requesting a community podiatry appointment Please tell us about the foot problem and why you are requesting a podiatry appointment. e.g. Foot pain, swelling, redness or discharge. How long have you had the problem? Do you have a fall or balance problem? Required Is treatment being received for any of the following? Please select ALL that apply. Diabetes Loss of sensation in feet Heart disease Poor circulation Please tell us about any other medical conditions that are currently being treated or have been treated in the past. Please list all medication you are currently taking. Please tell us about any allergies you have. Please give any other information you feel we should know or any help you need with the appointment. Are you able to take a photograph of the problem? If so, please use this prompt to help us better understand what the problem is. Submit
