Gloucestershire Podiatry Service (GPS)
Podiatry Referral
Gloucestershire Podiatry Service (GPS) aims to provide a comprehensive foot health service
to the local population to maintain mobility. Health Promotion underlies all podiatric activity
and patients are encouraged to take responsibility for assisting with their own foot health.
Social nail care is not provided by the GPS.
All areas of this form must be completed.
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Postcode
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Telephone No...…………………...............
Mobile No. ……………………………….
Title
Surname
Forenames
Address
Are you happy to receive text reminders? Yes/ No
Work No.
……………………………….
Appointments may be offered at short notice over the telephone
Date of Birth
NHS No.
Hospital No.
Podiatry No.
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…………………….. (office use only)
GP and Code …………………………..
Address
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Next of Kin / Chief Carer (where
appropriate)
Name
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Address
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Postcode
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Tel. No
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Relationship …………………………..
Referred By ………………………….
Self / GP / Other ………………………
Reason for referral (foot/lower limb problem)
DATE:
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Medical History (please attach full list of current medication)
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Recent Investigation and dates:
Blood test
X-ray /MRI scan
Microbiology
To enable the Podiatry department to offer the most appropriate assessment we require as much
information as possible. If necessary the referral may be returned for additional information.
OFFICE USE ONLY
MRN
Consent Triaged
to text
patient
Date
received
Date
Offered
Assessment
Date
Clinic
Gloucestershire Podiatry Service (GPS)
Podiatry Referral
CLINICS OF CHOICE
We aim to offer you an appointment within two weeks. To be able to achieve this we
may offer an appointment in an alternative clinic. Please indicate ALL of the locations
you are willing to attend.
Churchdown
Cinderford
Coleford
Dursley
Lydney
Newent
Rikenel – Gloucester
Stonehouse
Stroud
Tetbury
Wotton-Under-Edge
Bourton-on-the-Water
Cheltenham (St Paul’s Medical Centre /
For clinics above please forward
completed form to:-
For clinics above please forward
completed form to:-
The Podiatry Department
Gloucestershire Royal
Hospital
Great Western Road
Gloucester
GL1 3NN
The Podiatry Department
St. Paul’s Medical Centre
121 Swindon Road
Cheltenham
GL50 4DP
Independent Living Centre)
Cheltenham (Hester’s Way)
Cirencester
Fairford
Moreton-in-Marsh
Tewkesbury
Winchcombe
Domiciliary Visit (see below)*
If you have ticked clinics in both columns please send the form to EITHER
address. The Podiatry Department will offer an appointment at the clinic with
the shortest waiting time.
INFORMATION FOR HEALTH CARE PROFESSIONALS
Domiciliary Visiting
Gloucestershire Podiatry Services recognise that there may be a need for some
patients to be seen within their own home.
*Referrals for domiciliary assessment will ONLY be accepted via a letter from
the patients GP. Please include a detailed medical history/medications and eligibility
criteria for the domiciliary visit
Criteria
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
A housebound patient is classed as a patient who is unable to leave their home
without the need for an assisted escort with Patient Transport Services Ambulance
PTS/ hospital transport criteria C2+
Patients who are terminally ill /end of life.
For further information on Domiciliary criteria please telephone either
0300 422 8131 OR 01242 215470