Podiatry self-referral

Podiatry self-referral form

Please only complete this form if you are registered with a GP in the City and Hackney area.

If you are not your referral will not be accepted.

Personal details

Note: Questions marked by * are mandatory

Your health records and how they are used

Why do you collect information about me?

Your doctor and other health professionals caring for you keep records about your health and treatment from the National Health Service (NHS).
It is in the interest of the patient for a full record to be collected.

Your records are either written down (manual records), or held on a computer (electronic records).

These may include details about

your address and next of kin
your hospital visits
the treatment or the care you receive results of investigations and /or tests
information from other health professionals, relatives and those who care or know you well.

If you would like more information about your rights and how we process your personal information, please ask the receptionist for a copy of our Privacy Notice leaflet or look on our website www.homerton.nhs.uk and click on the Information Governance tab at the top of the page.

*This is a mandatory field. Title (Mr, Mrs, Miss)

*This is a mandatory field. First name

*This is a mandatory field. Family name

*This is a mandatory field. Date of birth

Gender

Male
Female
Other

NHS number

*This is a mandatory field. Email address

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Podiatry self-referral

Search the Homerton Healthcare NHS Foundation Trust website

Please only complete this form if you are registered with a GP in the City and Hackney area.

If you are not your referral will not be accepted.