This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
Presenting Complaint
Which service is this referral aimed at:
- General Podiatry
- MSK Podiatry
- Diabetes
- Nail Surgery
Is this a request for a domicilliary visit:
- Yes
- No
Main Presenting Complaint: [Text – 98 character maximum]
Reason for Referral: [Text]
Date of Onset: [Date]
Priority:
- Routine
- Urgent
Priority Reason: [Text – 98 character maximum]