Application for Podiatry Treatment Form

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.

Patient details:
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
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:

Data Protection (GDPR)

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

What are you looking for?

Operation	When