Richmond AQP Podiatry Referral Form
Urgent Referral eg ulcer, infection, pain, diabetic foot (increased risk)
PATIENTS DETAILS
PRACTICE DETAILS
Family Name:
Date of Referral:
First Name(s):
Referrer:
Date of Birth:
Referring GP:
Address:
Practice Address:
Telephone: Home
Telephone:
Telephone:
Mobile
Consent to leave
message:
Routine Referral
Fax:
Yes
No
Email:
Community:
NHS Number:
Treatment Site:
Gender:
Nursing/Residential Home:
Domiciliary:
Ethnicity:
Interpreter
Required:
Yes
No
GP Signature:
…………………………………
Language:
Which Service for which Patient?
AQP Podiatry:
Non Diabetic Patients with core Podiatry needs (following a 6w period of selfmanagement – use PIL/education etc
Simple Biomechanics
Nail Surgery
Superficial Ulcer MX
Diabetic Patients: LOW and INCREASED RISK (QOF criteria)
Annual Diabetic foot check – primary care provider
FAX referral to patient’s chosen provider
If patient does not meet AQP criteria, please refer through current Podiatry non AQP service (HRCH)
Non AQP Community Specialist Podiatry (HRCH):
Non Diabetic Patients at high risk ulceration: RhA + immunosuppressive drugs/long
term oral steroids/deep ulcers/chemo Rx patients
Complex Biomechanics
Diabetic Patients: HIGH RISK and actual ulceration
FAX TO HRCH: 020 8614 5457
Richmond AQP Podiatry Referral Form
Immediate Referral A&E
Critical ischemia or Diabetic foot emergency: Active Ulceration, spreading infection,
critical ischemia, gangrene or unexplained hot, red swollen foot +/- pain. (Suspected
Charcot joint)
Reason for referral
Routine skin/nail pathology
Non-specialist biomechanics
(Complex cases – refer to specialist
podiatry)
Superficial ulcer
Nail surgery
X-ray
Scan
Diagnosis of history
Medication
Allergies
Investigations
(please attach scan reports)
PATIENT: Please confirm your chosen provider by ticking one of the boxes below and please
pass to reception to fax
Healthshare Ltd: Fax: 0208 181 7818
Sheen Lane Health Centre
East Sheen, London SW14 8LP
Hampton Hill Medical Centre
94-102 High Street, Hampton Hill, TW12 1NY
Hampton Wick Surgery
26 Upper Teddington Road, KT1 4DY
Hounslow and Richmond Community Healthcare NHS Trust: Fax 0208 614 5457
Teddington Health and Social Care
Queens Road, Teddington, Middlesex, TW11 0LR
Centre
Ravenscroft Physiotherapy Centre: Fax: 01908 377 963
Cross Deep Surgery
2-4 Cross Deep, Twickenham, TW1 4EA
Queen Mary’s Hospital: Fax 0208 487 6424
Podiatry Services Administration
Roehampton Lane, SW15 5PN
NHS Podiatry does not provide a toenail clipping service for patients without a medical need. If this is
required, please provide appropriate self-care information or consider the following voluntary
organisations:
Elleray Hall Social Centre
020 8977 0549
Linden Hall Social Centre
Whitton Social Centre
Barnes Green Social Centre
The Avenue Club
020 8941 2373
020 8894 4963
020 8876 2377
020 8948 8807
RICHMOND PATIENT CHOICE OF PROVIDERS FOR AQP COMMUNITY PODIATRY
From 1st April 2013 patients should be offered a choice of where they can have their community
podiatry services. Urgent referrals will be seen in 72 hours and routine referrals within 10 working
days. Chosen providers will call and arrange appointments directly with patients. AQP providers
are:
Healthshare Ltd, Sheen Lane Health Centre, East Sheen, London, SW14 8LP;
Hampton Hill Medical Centre, 94-102 High Street, Hampton Hill, TW12 1NY and
Hampton Wick Surgery, 26 Upper Teddington Road, KT1 4DY. Contact Nick
McGrath, T 08450 030676 (local rate number), Fax 0208 181 7818.
Hounslow and Richmond Community Healthcare NHS Trust, Teddington Memorial
Hospital, Hampton Road, Teddington, TW11 0JL; Centre House Clinic, 68 Sheen
Lane, East Sheen, SW14 8LP; Ham Clinic, Ashburnham Road, Ham, Richmond,
TW10 7NF; Richmond Rehabilitation Unit, 22 Evelyn Road, Richmond, TW9 2TF; St
Johns Health Centre, Oak Lane, Twickenham, TW1 3PA and Whitton Corner Health
Centre, Percy Road, Whitton, TW2 6JL. Contact Stephen Clark, T 020 8614 5435
(central booking for all clinic sites, Fax 0208 614 5457.
Ravenscroft Physiotherapy Centre, Cross Deep Surgery, 2-4 Cross Deep,
Twickenham, TW1 4QP, Contact: Maxine Todd, T 01908 377963, Fax 01908 671210.
Queen Mary’s Hospital, Roehampton Lane, SW15 5PN, Contact: Podiatry
Administration, email: podiatry.appointment@stgeorges.nhs.uk, T 0208 4876426,
Fax 0208 487 6424.