REQUEST FOR DIABETES REFERRAL CENTRE APPOINTMENT
E-refer via ReferralNet (BH Outpatients)
Fax: 03 4215 1383
							
GP Referral
		Referral Date: Miscellaneous.Date
Feedback Requested:  Feedback requested

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

Referral Urgency: Referral Urgency
Referral valid for: Referral valid for		Referring General Practitioner:
Name:Treating Doctor.Name
Practice: Practice.Name
Address:Practice.Address
Phone:  Practice.Phone
Fax:  Practice.Fax
Email: Treating Doctor.E-mail
Provider No.: Treating Doctor.Provider Number	

Patient/Client/Consumer details:
Title: Patient Demographics.Title
First name: Patient Demographics.First Name
Surname: Patient Demographics.Surname
Preferred Name: Patient Demographics.Popular Name

Date of Birth: Patient Demographics.DOB       Age: Patient Demographics.Age
Gender: Patient Demographics.Gender 

ATSI: Patient Demographics.ATSI Status
Interpreter required: Interpreter
Preferred language is: Preferred language
Please consider Telehealth for this patient: Telehealth 
Cultural safety requirements: Cultural Safety
Access/Support requirements: Access/Support		Address: Patient Demographics.Full Address
Mobile: Patient Demographics.Phone (Mobile)
Email: Patient Demographics.E-mail
Home Phone: Patient Demographics.Phone (Home)
Work Phone: Patient Demographics.Phone (Work)
Preferred method of communication: Preferred contact 

Medicare: Patient Demographics.Medicare Number  Expiry: Patient Demographics.Medicare Expiry Date
Pension/HCC: Patient Demographics.Pension Number
DVA: Patient Demographics.DVA Number
Insurance: Patient Demographics.Health Fund NamePatient Demographics.Health Fund Member Number

NOK/Carer/Alternate contact:
Name: Patient Demographics.NOK Name  
Phone: Patient Demographics.NOK Mobile Phone
Relationship: Patient Demographics.NOK Relationship

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

WestVic HealthPathways provides guidance in patient assessment, management and referral. 
HealthPathways
Statewide Referral Criteria apply for Specialist Clinics Referrals. 
Referral criteria	

Reason for referral:
Reason for referral

General Diabetic Complications General Diabetes
Diabetic nephropathy: Diabetic Nephropathy	Worsening renal function: Renal Function	
Retinopathy:  Retinopathy	CVA: CVA	
IHD: IHD	Severe hypo: Severe hypo

Diabetic Foot Complications/ Ulcers Diabetic Foot	
Peripheral neuropathy: Peripheral Neuropath	Peripheral vascular disease: Peripheral vascular  	
Evidence of osteomyelitis: Osteomyelitis  	Previous amputations: Previous amputations	
Chronic ulcer : Chronic ulcer	Acute ulcer: Acute ulcer	
Resistant organism/Complex microbiology: Resistant organsim	Signs of soft tissue infection: Signs of soft tissue	
Charcot foot: Charcot foot	 If pt has signs of sepsis, refer to ED:( Sepsis)	

Previous relevant consultants or other Health Professionals involved in Mx of problem or related problem:
Previous consultant	
	
Other Health Professionals involved	Date of last visit	
Diabetes Educator Diabetes educator	Date- DE	
Dietician: Dietician	Date- dietician	

Podiatrist: Podiatrist	Date-podiatrist	

Optometrist/Ophthalmologist: Optometrist/Ophthalm	Date- optom/ophthal	

Past Medical History:
Clinical Details.Past History

Social History:
Clinical Details.Social History

Family History:
Clinical Details.Family History

Current Medications:
Clinical Details.Medication List

Alerts:
Clinical Details.Warnings

Allergies:
Clinical Details.Allergies

Alcohol History:
Clinical Details.Alcohol

Smoking Status:
Clinical Details.Smoking
If smoker, smoking cessation discussed: Smoking cessation

Investigations/Results: 
HbA1c, lipids, ACR, 
Clinical Details.Result List (Selected)

Electronically signed by: Treating Doctor.Name