GP - DIABETIC FOOT PODIATRY REFERRAL FORM
FOR PODIATRY ROUTINE & URGENT APPOINTMENTS.
Patient
First Name:
<Patient name>
Surname:
<Patient Name>
Address:
<Patient Address>
Telephone:
<Patient Contact Details>
Mobile:
NHS
Number:
Gender:
Interpreter
Required:
Referrer Details
GP Name:
<Sender name>
GMC
number:
Address:
<Referrals out>
<Organisation Details>
<Patient Contact Details>
Practice
code
Telephone:
<NHS number>
Fax No;
<Organisation Details>
E-mail:
Date of
Referral:
<Todays date>
<Gender>
Yes
DOB:
Language/
Ethnicity:
No
Clinic appointment
<Date of birth>
<Ethnicity>
ROUTINE
<Organisation Address>
<Organisation Details>
Email header must say ‘Urgent diabetic foot referral’.
URGENT (72 hours)
24 HOUR ASSESSMENT
Home Visit – patient MUST be housebound
Diabetes Type: <Diagnoses>
HbA1c: <Numerics>
Service Inclusion Criteria:
Service Exclusion Criteria:
1. Foot deformity (claw toes, hammer toes,
pes cavus, pes planus, Charcot
deformity)
2. Removal of corns and ingrowing toenails
regardless of risk level
3. Previous history of ulcer, amputation or
infection
4. Nail cutting regardless of risk level ONLY
if sight impairment, dexterity issues or
other disability preventing own nail cutting
(please state)
NICE Foot Risk Status (Please Tick)
Date: <Numerics>
1. Annual foot assessments
2. Nail cutting if inclusion criteria are not met
Definition
No Risk Factor:
Action

 Normal sensation
 Palpable pulses
LOW <Diagnoses>
LOW risk:
Does not meeting
inclusion criteria, will
not be seen by this
service
Annual diabetic foot
check by GP practice.
 Self-management.
 Give Diabetes UK leaflet
on LOW risk diabetic
foot care. (S1 OOH
Diabetes template)
https://www.diabetes.org.uk/Gui
de-to-diabetes/Monitoring/Feet/

One Risk Factor:
 Neuropathy OR
MODERATE <Diagnoses>
Name; <Patient name>

 Absent pulses
WITHOUT skin
changes/deformity
DOB; <Date of birth>

Give Diabetes UK leaflet
on MODERATE risk
diabetic foot care (S1
OOH Diabetes template)
Routine referral to
podiatry if clinical need
3-6 monthly
surveillance by GP
practice if not referred
to podiatry
NHS: <NHS number>
pg 1/2
GP - DIABETIC FOOT PODIATRY REFERRAL FORM
FOR PODIATRY ROUTINE & URGENT APPOINTMENTS.
Previous Ulcer or
Amputation

Or more than one Risk
Factor:
 Neuropathy
 Absent pulses
 Skin changes/Foot
deformity
HIGH <Diagnoses>

Give Diabetes UK leaflet
on HIGH risk diabetic
foot care (S1 Diabetes
OOH Template)
Routine referral for
Podiatry surveillance

ACTIVE Foot ulceration /suspected Charcot foot
<Diagnoses>





Active ulcer
Spreading Infection
Gangrene
Unexplained
hot/red/swollen foot
with or without pain
(suspect Charcot)



Give advice/leaflet on
Diabetic foot ULCER.
(S1 Diabetes OOH
Template)
Refer to Podiatry for 24
hour assessment if
weekdays
Request X-Ray/Swab
Initiate Antibiotics:
Flucloxacillin/Coamoxiclav or
Erythromycin if penicillin
allergy
Admit to Hospital if
systemically unwell
(fever, sweating,
shivering, chills) or
critical ischemic limb
Presenting complaint
<Event Details>
Past Medical History
<Summary(table)>
Problems:
<Problems(table)>
Allergies
<Allergies & Sensitivities>
Medication:
<Repeat Templates>
Send all referrals to the REFERRAL FACILITATION SERVICE:
as an email attachment to [email protected] For practice enquires please telephone: 05511 434910
For 24 and 72 hour referrals email header must say ‘Urgent diabetic foot referral’.
CLCH routine and urgent clinical queries helpline:
07815716838
Email contact for routine clinical queries: [email protected]
Name; <Patient name>
DOB; <Date of birth>
NHS: <NHS number>
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