Podiatry Self-referral form

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This field is for validation purposes and should be left unchanged.

Confidential Application for Podiatry Treatment

Please read the Podiatry Clinic’s Policy Notice.

Please note: Due to very high demand there is currently a 3-4 month wait time for all new patient appointments. To continue with your application, please click the 'Next' button below.

Patient details:

The next bookings for our student clinics will be September/October 2026.

We will book your initial appointment into the next available slot, either with a graduate podiatrist or a self-employed private podiatrist. These are charged at £40 and £70. Please continue completing this form if you are happy with the above statement. If you wish to wait to see a student, please re-visit this form in August/September 2026.

I confirm I am happy with the above statement

We have the following options for your first appointment:*

Please select which clinician/s you would be happy to see (tick all that apply)

£28 - Student Podiatrist – 2-4 months wait times (Student clinics run Oct - May)

£70 – Private Senior Podiatrist – 4-5 week wait times

Is this application for a child under 16:*

Please let us know if the application is for a child under 16

Yes

No

Is the patient a UON staff member or student?*

Yes

No

Have you/the patient, previously attended the clinic, or completed a self-referral application form?*

(We ask this to avoid creating duplicate accounts for patients who may have registered with us previously, but may not yet have attended an appointment)

Yes

No

Patient's name*

Please let us know the patient's title and name.

Title First name Surname

Patient's Date of Birth*

Please enter the patient's date of birthday in a DD/MM/YYYY format.

Patient's address*

Please enter the patient's address.

Address line 1 Address line 2 Town County Post code

Patient's mobile number:*

Please enter the patient's mobile number.

Alternative contact number:

If the patient has an alternative contact number, please include it.

Patient's Email:*

Please enter and confirm the patient's email address.

Enter email Confirm email

Emergency contact:

Emergency contact's name*

Please enter the patient's emergency contact including title.

Title First Name Surname

Emergency contact's address*

Please enter the address of the patient's emergency contact.

Address line 1 Address line 2 Town County Post code

Emergency contact's mobile number:*

Please enter the mobile number of the patient's emergency contact.

Emergency contact's alternative contact

If the patient's emergency contact has an alternative contact number, please enter it below.

Doctors details:

Doctor's Surgery*

Please tell us the name of the patient's Doctor's Surgery.

Surgery address:*

Please tell us the address of the patient's Doctor Surgery.

Address line 1 Address line 2 Town County

Consent of Treatment:

Privacy Notice

Our Policy Notice is available on the main Podiatry Clinic webpage.

Confirmation of podiatrist treatment*

Please confirm if you are happy to be seen by a podiatrist and that all information in this form is correct and up to date.

I confirm

Confirmation of payment*

Please confirm that you agree to pay due charges for appointments and treatment.

I agree

Name of legal parent or guardian*

Please provide the name of the legal guardian or parent as the child is under 16 years old.

Title Forename Surname

Relationship to patient*

Please tell us the relationship of the legal parent or guardian to the patient.

What are you looking for?

Courses

Events

Staff

Application for Podiatry Treatment.

Patient details:

Emergency contact:

Doctors details:

Podiatry/Chiropody problem:

Your medical history:

Consent of Treatment:

Privacy Notice