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Referral form

Podiatry (foot care)

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GP details
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Emergency contact
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Reason for referral
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(use as much detail as possible)
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For example, does it disturb your sleep or interfere with your normal activities?
Which of the following applies to you?:
(tick all that apply)




















(whether prescribed by your GP or bought yourself), any regular injections or complementary remedies (including vitamins)
Do you give consent for us to do any of the following:
(tick all that apply)






We ask the following questions about ethnicity and sexual orientation to ensure that it meets the needs of the demographic population of Medway.

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(where you would like the confirmation email sent)

You are welcome to bring someone with you to your appointment but you should bear in mind you will be asked details about your health problems and you may not wish to discuss these in front of your companion. There are no changing rooms at any of our clinics.

You will see a thank you page once the form has been submitted. If you do not see this page then you have overlooked to complete some of the required fields. Please check the form, complete the missing details and resubmit. Thank you.

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