Podiatry - online request for appointment :: Derbyshire Community Health Services

About the patient

Title

Mrs

Miss

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

Postal Code

Telephone number

Mobile number

Email Address Required

I consent to receive mobile text appointment reminders

Yes

I consent for messages to be left on my home phone

Yes

I consent for messages to be left on my mobile phone

Yes

I consent for you to view my Summary Care Record Required

Yes

I need an interpreter

Yes

I consent to share my electronic records Required

Yes

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.

Contact Us:

For any queries regarding appointments and referrals, please contact your nearest clinic.

Most clinics are open 8:30 am – 5:00 pm; Monday to Friday. However, there are extended opening times at designated clinics and locations. Please contact your nearest clinic for up-to-date opening hours and services available.

For more information, please click here.

Podiatry - online request for appointment

About the patient

Contact details

Reason for requesting a community podiatry appointment

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