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Confidential Application for Podiatry Treatment
Please note: Due to very high demands there is currently a 2-3 month wait time for all new patient appointments, if you wish to continue with your application, please click the 'Next' button below.
Please let us know if the application is for a child under 16
Please let us know the patient's title and name.
Please enter the patient's date of birthday in a DD/MM/YYYY format.
Please enter the patient's address.
Please enter the patient's mobile number.
If the patient has an alternative contact number, please include it.
Please enter and confirm the patient's email address.
Please enter the patient's emergency contact including title.
Please enter the address of the patient's emergency contact.
Please enter the mobile number of the patient's emergency contact.
If the patient's emergency contact has an alternative contact number, please enter it below.
Please tell us the name of the patient's Doctor's Surgery.
Please tell us the address of the patient's Doctor Surgery.
Please explain your condition and why you are coming to our podiatry clinic.
What is / are the main concern(s). Select all applicable.
Where on the body is the main concern?
Please let us know how long this has been a concern (days / weeks / years).
Has any medical treatment been received for this problem?.
Please give details of what medical treatment has been received including how, where, and who.
Is the patient currently taking any medication?
Please list all medications and bring a list with you to your first appointment. (Click the plus button to add more items).
Please tell us if the patient has any known allergies.
Please tell us the allergies of the patient. (Click the plus button to add more items).
Does the patient have any other medical or physical conditions?
Please tell us what other medical or physical conditions the patient has.
If you selected the 'Other' option, please state your conditions. (Click the plus button to add more items).
Has the patient had any previous medical operations?
Please tell us what previous medical operations the patient has had and when.
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 University's 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 confirm if you are happy to be seen by a podiatrist and that all information in this form is correct and up to date.
Please confirm that you agree to pay due charges for appointments and treatment.
Please provide the name of the legal guardian or parent as the child is under 16 years old.
Please tell us the relationship of the legal parent or guardian to the patient.