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Richmond AQP Podiatry Referral Form


Urgent Referral eg ulcer, infection, pain, diabetic foot (increased risk) Routine Referral

PATIENTS DETAILS

PRACTICE DETAILS

Family Name:




Date of Referral:




First Name(s):




Referrer:




Date of Birth:




Referring GP:




Address:




Practice Address:



Telephone: Home




Telephone:




Telephone: Mobile




Fax:




Consent to leave message:

Yes No


Email:




NHS Number:




Treatment Site:

Community:

Nursing/Residential Home:

Domiciliary:



Gender:




Ethnicity:




Interpreter

Required:



Yes No


GP Signature:

…………………………………



Language:






Which Service for which Patient?

AQP Podiatry:

Non Diabetic Patients with core Podiatry needs (following a 6w period of self-management – use PIL/education etc

Simple Biomechanics

Nail Surgery

Superficial Ulcer MX

Diabetic Patients: LOW and INCREASED RISK (QOF criteria)

Annual Diabetic foot check – primary care provider

FAX referral to patient’s chosen provider

If patient does not meet AQP criteria, please refer through current Podiatry non AQP service (HRCH)




Non AQP Community Specialist Podiatry (HRCH):

Non Diabetic Patients at high risk ulceration: RhA + immunosuppressive drugs/long term oral steroids/deep ulcers/chemo Rx patients

Complex Biomechanics

Diabetic Patients: HIGH RISK and actual ulceration



FAX TO HRCH: 020 8614 5457


Richmond AQP Podiatry Referral Form


Immediate Referral A&E

Critical ischemia or Diabetic foot emergency: Active Ulceration, spreading infection,

critical ischemia, gangrene or unexplained hot, red swollen foot +/- pain. (Suspected

Charcot joint)




Reason for referral

Routine skin/nail pathology


Non-specialist biomechanics



(Complex cases – refer to specialist podiatry)

Superficial ulcer


Nail surgery



Diagnosis of history




Medication




Allergies




Investigations

X-ray



Scan




(please attach scan reports)




PATIENT: Please confirm your chosen provider by ticking one of the boxes below and please pass to reception to fax




Healthshare Ltd: Fax: 0208 181 7818




Sheen Lane Health Centre

East Sheen, London SW14 8LP




Hampton Hill Medical Centre

94-102 High Street, Hampton Hill, TW12 1NY




Hampton Wick Surgery

26 Upper Teddington Road, KT1 4DY




Hounslow and Richmond Community Healthcare NHS Trust: Fax 0208 614 5457




Teddington Health and Social Care Centre

Queens Road, Teddington, Middlesex, TW11 0LR




Ravenscroft Physiotherapy Centre: Fax: 01908 377 963




Cross Deep Surgery

2-4 Cross Deep, Twickenham, TW1 4EA




Queen Mary’s Hospital: Fax 0208 487 6424




Podiatry Services Administration

Roehampton Lane, SW15 5PN







NHS Podiatry does not provide a toenail clipping service for patients without a medical need. If this is required, please provide appropriate self-care information or consider the following voluntary organisations:

Elleray Hall Social Centre

020 8977 0549

Linden Hall Social Centre

020 8941 2373

Whitton Social Centre

020 8894 4963

Barnes Green Social Centre

020 8876 2377

The Avenue Club

020 8948 8807


RICHMOND PATIENT CHOICE OF PROVIDERS FOR AQP COMMUNITY PODIATRY

From 1st April 2013 patients should be offered a choice of where they can have their community podiatry services. Urgent referrals will be seen in 72 hours and routine referrals within 10 working days. Chosen providers will call and arrange appointments directly with patients. AQP providers are:




H

ealthshare Ltd, Sheen Lane Health Centre, East Sheen, London, SW14 8LP; Hampton Hill Medical Centre, 94-102 High Street, Hampton Hill, TW12 1NY and Hampton Wick Surgery, 26 Upper Teddington Road, KT1 4DY. Contact Nick McGrath, T 08450 030676 (local rate number), Fax 0208 181 7818.



H

ounslow and Richmond Community Healthcare NHS Trust, Teddington Memorial Hospital, Hampton Road, Teddington, TW11 0JL; Centre House Clinic, 68 Sheen Lane, East Sheen, SW14 8LP; Ham Clinic, Ashburnham Road, Ham, Richmond, TW10 7NF; Richmond Rehabilitation Unit, 22 Evelyn Road, Richmond, TW9 2TF; St Johns Health Centre, Oak Lane, Twickenham, TW1 3PA and Whitton Corner Health Centre, Percy Road, Whitton, TW2 6JL. Contact Stephen Clark, T 020 8614 5435 (central booking for all clinic sites, Fax 0208 614 5457.



R

avenscroft Physiotherapy Centre, Cross Deep Surgery, 2-4 Cross Deep, Twickenham, TW1 4QP, Contact: Maxine Todd, T 01908 377963, Fax 01908 671210.



Q


ueen Mary’s Hospital, Roehampton Lane, SW15 5PN, Contact: Podiatry Administration, email: podiatry.appointment@stgeorges.nhs.uk, T 0208 4876426, Fax 0208 487 6424.


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