Podiatry Outpatient Referral Form
All referrals to Northern Network Access and Referral Centre (NNARC)
Phone: 02 93690400      Fax: 02 9369 0101
Enquiries to Podiatry Department Phone: 9369 0219

Today's Date: <<Miscellaneous:Date (short)>>
Client Details
Name	 <<Patient Demographics:Full Name>>	DOB	 <<Patient Demographics:DOB>>	
Address	 <<Patient Demographics:Full Address>>	Phone	 (h) <<Patient Demographics:Phone (Home)>>     (w) <<Patient Demographics:Phone (Work)>>     (m) <<Patient Demographics:Phone (Mobile)>>	

  Eligibility Criteria (please tick)                              Exclusion Criteria (please tick)
	Diabetes Mellitus			General nail and foot care without medical conditions	
	Peripheral Neuropathy			Unable to transfer onto treatment chair	
	Current (or Hx) of foot ulcer 			Nail surgery	
	Peripheral Vascular Disease			Level 3 & 4 Home Care Packages	
	Neurological and Neuromuscular conditions			NDIS	
	Inflammatory joint conditions			Team Care Arrangements, CDMP & EPC	
	End Stage Renal Failure			Living in residential aged care facilities	
	History of pedal amputation			Gold card DVA holders without foot ulcer or amputation	
	Foot deformity			White card DVA holders with podiatry	
	Social isolation or unable to seek private podiatry services				

Can this patient access private podiatry services?
[     ]   No
[     ]   Yes - ineligible
Further comments: (Please attach medical health summary to referral form).
_________________________________________________________

Referring Doctor’s Name:
 <<Doctor:Name>>	Phone:
 <<Doctor:Phone>>	
Address:
 <<Doctor:Full Address>>	Fax:
 <<Doctor:Fax>>