Refer Online

Online Referral Form

Complete the secure referral form below to refer your patient to Knox High Risk Foot Clinic. All information is transmitted securely and confidentially.

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- Step 1 of 3

Date of Referral *

Name *

First

Last

GenderMaleFemaleOtherRather not say

Referrer's for Clinic

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

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Phone *

GP Name *

GP Clinic *

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Reason for Referral *

• Active or chronic diabetic foot wound
• Active of chronic neuropathic foot wound
• Vascular patient requiring podiatry input
• Wound clinic patient requiring podiatry input
• Post amputation/surgical debridement wound
• A high risk foot patient requiring long term offloading assessment and planning
• High risk foot neurovascular assessment and patient education
• Other

If other, please specify

Urgency of Referral *

• Urgent (Assessment within 1-2 weeks)
• Medium Priority (Assessment within 2-3 weeks)
• Routine (Assessment within 4 weeks)

Next

Additional Notes and Concerns

Referring practitioner *

First

Last

Referrer's phone number

Referrer's email address

Provider Number

Does this referral also include referral to a vascular surgeon if required?

• Yes
• No

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