Deadly Feet Self Referral Form

Use this form to self-refer yourself or a family member to the Deadly Feet program.

To access this program you must be of Aboriginal and/or Torres Strait Islander origin.

Details of the person being self-referred

Name(Required)

First Last

Date of birth(Required)

Contact details ( eg: phone number, email)(Required)

If you provided a phone number, what's the best time and day to call?

Identify as(Required)

Aboriginal

Torres Strait Islander

Aboriginal and Torres Strait Islander

Address(Required)

Street Address Address Line 2 Suburb/Town State Post code

OR

No fixed address

Do you have a regular GP or GP Practice?

Yes

No

GP Details (if available)

Regular General Practitioner (GP)

GP practice name

Practice phone number

Reason for referral to Deadly Feet clinic

Your concern(Required)

I am concerned about my foot health

I smoke or used to smoke

I have diabetes

I have kidney disease

Additional information (if required)

Upload photos (if you have any)

Must be jpg, jpeg or png format only

Drop files here or

Accepted file types: jpg, jpeg, png, Max. file size: 10 MB, Max. files: 6.

Do you want a copy of this referral?

If you would like a copy of this referral for your records, please provide an email address below:

Email

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Collection notice

Queensland Health (QH) is required to manage your personal information in accordance with the Information Privacy Act 2009 and the Hospital and Health Boards Act 2011, Part 7 Confidentiality. QH is collecting the personal information on this form to assist in preparation for your clinic appointment and to assess your individual health care needs. This form will be printed and filed in your patient medical record. Some of your personal information on your medical record may be given to carers, guardians or other government departments who provide associated services that require your information for the purpose of providing a health care service. Your information will be disclosed without your consent, if authorised or required by law. For further information about privacy and your health record please ask for a copy of the Queensland Health Privacy Brochure or visit www.health.qld.gov.au.

Your foot health, closer to home.

Details of the person being self-referred

GP Details (if available)

Reason for referral to Deadly Feet clinic

Do you want a copy of this referral?

Collection notice

Details of the person being self-referred

GP Details (if available)

Reason for referral to Deadly Feet clinic

Do you want a copy of this referral?

Contact us

Having trouble submitting the form?