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Liverpool Podiatry Services

longer healthier lives Liverpool Community Health

Community Podiatry Assessment Self Referral Form

Please complete all sections of the application form.

Priority will be given to applicants based on the risk and impact of their condition.

Incomplete applications cannot be prioritised and will be returned to the referrer; this may result in a delay to assessment.

Click here to download the application form (PDF, 88KB)

Once you have completed the application form then you can either hand it to the surgery to fax it back to Liverpool Podiatry Services OR you can fax it your self to Liverpool Podiatry Services using the following number Fax: 0151 295 9466

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