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Podiatry self-referral form

***Our Podiatry referral form for patients registered with a GP in Alton, Andover, Eastleigh, Winchester and Basingstoke is not working at present***

Please do not complete this referral form yet. Check back on this page for when this message has been removed and the temporary issue has been resolved.

The referral form for patients registered with a GP in Portsmouth, Southampton, West and East Hampshire is up and running as normal and can be found here.

Podiatry Self-referral form

Please note: Following submission of your form, your referral will be passed to our teams for triage and you will be added to a wait list. The podiatry team will contact you when they are in a position to offer an appointment.

If you have any issues you can contact our central booking office by calling 02382 313030 or  PodSelfReferral@southernhealth.nhs.uk

 

Required
Required
Date of Birth Required
Europe/London
Address
Required

If you dont know your NHS number you can find it here 

Required
Required
Are you happy for us to leave a message on this number? Required

Type of referral: Ingrowing toenail

Are you diabetic? Required
Required
Which foot is affected? Required
How long have you had the problem? Required
Was the onset gradual or immediate? Required
Has the pain gotten worse or remained the same? Required
Required
Required
Required
Are there any signs of infection? Required

Medical history, allergies and current medication

Do you have any allergies? Required
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