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Confidential Application for Podiatry Treatment
This form has implemented reCAPTCHA v2 this is the used to fight spam and abuse on this form.
Please tick the "I'm not a robot" box and follow any instructions.
When the green tick shows click on 'Next' to continue.
All treatment is based on medical needs
In line with the General Data Protection Regulations (GDPR) we need to inform you that the personal data supplied is held on our hosted patient record system (on the University’s UK server) and also in paper form (gathered patient notes) secured within the Podiatry Clinic it will also be on the Universitys email system. Your data will not be used for marketing purposes or given to a third party to use unlawfully. Your details will be used for teaching and medical purposes only and when applicable your details would be shared with other medical professionals with further consent.
Please click the submit button to submit your self-referral form to our Podiatry Clinic administration team.
The team will review your referral and contact you directly within 5 working days with an appointment date.