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)
- £40 - Podiatrist - 1-3 months wait times
- £60 – Private Podiatrist (Shermin) – Wednesdays only
- £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.
DD slash MM slash YYYY
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

Your medical history:
Any medical or physical conditions?*
Does the patient have any other medical or physical conditions?
- Yes
- No
Other medical or physical conditions*
Please tell us what other medical or physical conditions the patient has.
- Diabetes
- Circulation problems
- Immunosuppression
- Rheumatoid arthritis
- Osteoarthritis
- Stroke
- Heart problems
- Physical disabilities
- Registered blind or partially sighted
- Special educational needs
- Congenital problems
- Neurological
- Terminal illness
- Dementia
- Hearing loss or impairment
- Other (please state below)
Please state any other conditions*
If you selected the 'Other' option, please state your conditions. (Click the plus button to add more items).
Any previous medical operations?*
Has the patient had any previous medical operations?
- Yes
- No
Other medical operations*
Please tell us what previous medical operations the patient has had and when.
Operation When

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

Operation	When