PRIVATE & CONFIDENTIAL Version 9 (20.4.2021)

REFERRAL FORM 
for North Warwickshire
	PODIATRY including: 
Multi-Disciplinary Diabetes Foot Clinic (MDFT)
& Diabetes Foot Protection Team (FPT)		
Send this form via email to: 
podiatryreferrals@swft.nhs.uk 
or for advice: 

Tel:  01926 600818 option 4 
Podiatry iSPA
Heathcote House
Heathcote Lane
Warwick  CV34 6SR	Referred from: 	Registered GP Organisation Name 	
	Referrer:	Free Text Prompt 	
	GMC/NMC/HCPC Pin (optional):  	     	
	Job Role:	      	
	Address (including Postcode)	Registered GP Full Address (stacked) 	
	Contact Tel:	Registered GP Phone Number 	
	Contact email:	     	

Referral Date:	Wednesday, 21 April 2021			
PATIENT NAME:
ADDRESS:
TEL:	Full Name 
Home Full Address (stacked) 
Patient Home Telephone Patient Mobile Telephone 			
D.O.B:	Date of Birth 	NHS no:	NHS Number 	
Registered GP Name and Address	Registered GP Full Name 
Registered GP Organisation Name
Registered GP Full Address (stacked)			
Which service required:
                                            URGENT*  
                                              
                                              Routine  
    
 Photos available to view on EMIS: yes  	Multi-Disciplinary Diabetes Foot Clinic 
Podiatry/Foot Protection Team              
			
Reason for referral	e.g. Current problem / Onset / Duration  with details of: Infection/Ulceration/suspected Charcot/ Neuropathy/Ischaemia/Ingrowing toenail/Callus/Deformity of bone or nail Other professionals involved:

     

Consultations 			
Any other relevant information	Diabetic foot risk assessment
Single Code Entry: Diabetic foot risk assessment  			
Medical History/Significant Past	Problems 			
Medication List: Acute/Repeat	Medication 			
For Further information
Hyperlink to Pathway	https://www.swft.nhs.uk/   (Our services-Adult out of hospital- Podiatry)			
*IMPORTANT NOTE:
Most forms we receive are marked as ‘urgent’ – To enable us to triage and appoint those patients at greatest risk of amputation as soon as possible it is important that the information provided is complete, relevant and accurate.
URGENT Patient Pathway will be triaged within 1 working day meeting the Active Foot Problem criteria
Complicated Active Diabetes foot problems will be booked via Triage into the Multi-Disciplinary Foot Team at GEH

You must ACT NOW IMMEDIATELY if you have identified any limb or life threatening foot problem. In any cases of:
VASCULAR FOOT EMERGENCY
ACUTE or CRITICAL LIMB ISCHAEMIA; WET GANGRENE DEEP SEATED SEVERE INFECTION +/- SEPSIS  REFER DIRECTLY FOR ADMISSION/URGENT OPINION TO on-call VASCULAR REGISTRAR A&E DEPARTMENT UHCW Tel 024 7696 4000
ACTIVE FOOT INFECTION
Spreading Cellulitis, SEPSIS or fever secondary to foot infection not in Vascular Risk above
REFER DIRECTLY TO George Eliot Hospital- SDEC:Tel:024 7686 5617- or out of hours A&E 024 7615 3761/3762