REQUEST FOR DIABETES REFERRAL CENTRE APPOINTMENT
E-refer via ReferralNet (BH Outpatients)
Fax: 03 4215 1383

GP Referral
		Referral Date: <TodaysDate>

Feedback Requested:  Yes	

Referral to:
Diabetes Referral Centre (DRC)
Head of Unit: Dr Kimberly Cukier

Ph: 03 4215 1390
GP Hotline: 03 4215 1398
Fax:  03 4215 1383

Service requested: <Service Requested:>
Urgency:  <Urgency>
Referral valid for:  <Referral valid for:>			Referring General Practitioner:
Name:<DrName> 
Practice: <Practice> 
Address:<UsrAddress>
Phone: <UsrPhone>   
Fax:  <UsrFax>
Email: <DrEmail>
Provider No.: <DrProviderNo>

Patient/Client/Consumer details:
Title: <PtTitle>
First name: <PtFirstName> 
Surname: <PtSurname>
Preferred Name: <PtPrefName>
Date of Birth: <PtDoB>   Age: <PtAge>
Sex at Birth: <PtSex>
Gender Identity: <GenderIdentity>
ATSI: <PtEthnicity>

Interpreter required: <Does the patient require an interpreter?>
Preferred language is: <If interpreter needed, which language>
Please consider Telehealth for this patient:
<Please consider Telehealth for this patient:>
Cultural safety requirements: <Cultural safety requirements?>
Access/Support requirements: <Access/Support requirements?>		Address: <PtAddress>
Mobile: <PtPhoneMob>
Email: <PtEmail>
Home Phone: <PtPhoneH>  
Work Phone: <PtPhoneWk>
Preferred method of communication: <Patient's preferred contact method>

Medicare: <PtMCNo> <PtMCLine> Expiry: <PtMCExpiry>
Pension/HCC: <PtPensionNo>
DVA: <PtDVANo>
Insurance: <PtInsFund> <PtInsNo>

NOK/Carer/Alternate contact:
Name: <NOKName>  Phone: <NOKContact>
Relationship: <NOKRelation>

	

Consent to referral: <Consent to referral>  
Consent to share information: <Consent to share information>
Is this a 2nd referral for the same problem: <Is this a 2nd referral for the same problem?>
Usual GP (if not referrer):  <Usual GP (if different to referrer)- Name/Practice>	

WestVic HealthPathways provides guidance in patient assessment, management and referral. 
 			<HealthPathways Barwon guidance in Ax Mx referral>
Statewide Referral Criteria apply for Specialist Clinics Referrals. 
<Statewide Referral Criteria apply for Specialist Clinics Referrals.>	

Reason for referral:
<Reason for Referral>

General Diabetes Complications <General Diabetes Complications?>
Diabetic nephropathy:  <Diabetic nephropathy?>	Worsening renal function:  <Worsening renal function?>	
Retinopathy:  <Retinopathy?>	IHD: <IHD?>	
CVA:  <CVA?>	Severe hypo:  <Severe hypo?>	

Diabetic Foot Complications/ Ulcers <Diabetic Foot Complications / Ulcers?>
Peripheral neuropathy: <Peripheral neuropathy?>	Peripheral vascular disease: <Peripheral vascular disease>	
Evidence of Osteomyelitis: <Evidence of osteomyelitis>	Previous amputations: <Previous amputations>	
Chronic Ulcer: <Chronic ulcer> 	Acute Ulcer: <Acute ulcer>	
Signs of soft tissue infection:<Signs of soft tissue infection - cellulitis, pus etc>
	Resistant organism/complex microbiology: <Resistant organism/complex microbiology> 	
<If the patient has signs of sepsis, refer to ED>	Charcot Foot: <Charcot Foot?>	

Previous relevant consultants or unit involved in Mx of problem or related problem:
<Previous consultant/s involved in Mx of problem>

Is the patient also seeing:	Date of last appointment	
Diabetes Educator: <Is the patient also seeing a Diabetes Educator?> 	<Date of last visit to diabetes educator>	
Dietician: <Is the patient also seeing a Dietitian?> 	<Date of last visit to dietitian>	
Podiatrist:  <Is the patient also seeing a Podiatrist?>	<Date of last visit to podiatist>	
Optometrist/Ophthalmologist: <Is the patient also seeing an Optometrist/Ophthalmologist ?>	 <Date of last optometry/ophthalmology visit>	

Past Medical History:
<PMHActive>

Social History:
<SocialHx>

Family History:
<FamilyHx>

Current Medications:
<CurrentRx>

Alerts:
<Comment>

Allergies:
<Reactions>

Alcohol History:
<AlcHx>

Smoking Status:
<SmkStatus>
If smoker, smoking cessation discussed: <If smoker, smoking cessation discussed?>

Investigation Results:
<Please include HbA1c, lipids, ACR, UEs>
<Ix>

Electronically signed:  <DrName>