Podiatry Diabetes Clinic Priority: Urgent Active Diabetic Foot Disease – Patients Full Name and Address (or Patient Label): Patient Phone No: MRN/Hospital No: Patient D.O.B: NHS No: Patients GP and Surgery: Full name, job title and contact details of referring staff: Date of referral: / / Office use only: Book for: Tues am/Wed am/Thurs am Delete as appropriate. If no preference do not delete. Appointment Details: – Overbook Permission: No/ Yes Criteria for referral below - for all other foot problems e.g. ingrowing toenails, painful corns etc. please use the Community Podiatry application form. Additional information: Please forward this form by email to: *01908 OR FAX: 997732 *NB: please call Milton Keynes Hospital on 01908 997002 to confirm receipt of fax.
Podiatry Diabetes Clinic Priority: Urgent – Active Diabetic Foot Disease Patients Full Name and Address (or Patient Label): Patient Phone No: MRN/Hospital No: Patient D.O.B: NHS No: Patients GP and Surgery: Full name, job title and contact details of referring staff: Date of referral: / / Office use only: Appointment Details: Book for: Tues am/Wed am/Thurs am Delete as appropriate. If no preference – do not delete. Overbook Permission: No/ Yes Criteria for referral below - for all other foot problems e.g. ingrowing toenails, painful corns etc. please use the Community Podiatry application form. Additional information: Please forward this form by email to: OR FAX: *01908 997732 *NB: please call Milton Keynes Hospital on 01908 997002 to confirm receipt of fax.