SLHD PODIATRY INTAKE FORM

To assist us determine your patient’s needs and facilitate booking, please complete this intake form or attach a referral letter / consult form containing the following information. Fax or email to our central intake office.
If the consultation is urgent – Please telephone . PLEASE PRINT CLEARLY and complete all fields. 

Date: <<Miscellaneous:Date (short)>>
Patient full name:
<<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>>  <<Patient Demographics:Surname>>

DOB:<<Patient Demographics:DOB>>	Address:
 <<Patient Demographics:Address>> <<Patient Demographics:City>> <<Patient Demographics:State>> <<Patient Demographics:Postcode>>	Patient contact number:
(H) <<Patient Demographics:Phone (Home)>>
(M) <<Patient Demographics:Phone (Mobile)>>
	
Referring Doctor's name: <<Doctor:Name>>
	Practice Address
<<Doctor:Address>> <<Doctor:City>> <<Doctor:State>> 	Phone: 
<<Doctor:Phone>>
Fax: 
<<Doctor:Fax>>	
What is the reason for referral / foot pathology ? <<Reason for referral / foot pathology ?>>

Patients will be allocated appointments according to intake prioritising on the basis of clinical need.	

FOR Aged Care Referrals: Does your patient consent to referral through MyAgedCare: <<Patient consent to referral through MyAgedCare ?>>

Please tick if applicable.
	Current foot ulceration	
	Past foot ulceration or amputation	
	Evidence of Peripheral Arterial Disease	
	Evidence of Peripheral Neuropathy	
	Severe foot deformity	
	Diabetes (without evidence of foot complications or not yet assessed)	
	Psychiatric illness	
	Disability. Give details	
	End Stage Renal Disease	
	Patient holds a Pension or Health Care Card	

Frail elderly people requiring foot care to maintain (or recover) independence** are usually eligible for foot care under the Commonwealth Home Support Program (CHSP - formerly HACC) for which SLHD Podiatry is currently a service provider. If assistance with foot care is needed, in the absence of significant foot pathology, please refer through My Aged Care (MAC). This is the online portal for all aged care services. Following referral, patients are contacted by the Regional Assessment Service (RAS) to determine their aged care needs.
MAC REFERRALS: Phone: 1800 200 422 or complete the online referral at:   www.myagedcare.gov.au

You may still refer direct to SLHD Podiatry using this SLHD form. However, as we need to put the referral into MAC for CHSP eligible clients**, please obtain & indicate (above) your patients’ consent for this.	

Other relevant medical history:
<<Clinical Details:History List>>
	
Current medications: (attach list if there is insufficient space)
<<Clinical Details:Medication List>>
	
Allergies:
<<Clinical Details:Allergies/Adverse Reactions>> 
	
  <<GP requires notification of patient appointment>>  Please indicate if you require us to advise you of your patient’s appointment.	
For office use only.   Date received:

Appointment time /date: