Diabetes Referral Form

To make a referral to Star Health, please fill out the information below.


Referrer Details

Referrer Name*

Referrer Organisation*

Referrer Position*

Referrer Phone*

Referrer Email*

Referrer Fax



Client Details

Client Family Name*

Client Given Names*

Client Date Of Birth (dd/mm/yyyy)*

Client Gender*

Client Home Address*

Client Contact Phone Number*

Alfred UR

Client Country of Birth*

Is the client of Aboriginal or Torres Straight Islander origin?*

Does the client have a refugee status?*

Does the client require an interpreter?*

If yes, please state preferred language

Is the client living in insecure housing?*

 
Client Medicare Number* (Enter NA if not available)

Please give details of the client's current GP (GP name, Practice name, Address, Phone)*

Does the client hold any of the following concession cards?*

 

Diabetes Referral Questions

The above patient was:*

by the Diabetes Education team at the Alfred hospital during their admission in

for

 

Reason for community referral

Please specify the details*

Please indicate the reasons below.
T1DMT2DMCFRDSIDMHbA1c
Diabetes Duration

OHA's

Insulin / Other Injections

Steroids / Other Medications

 

History

Medical History

Social / Work Situation

 

Education

Education provided at The Alfred*
Nil/Not SeenSelf-blood glucose monitoringInsulin therapyNDSS registrationSelf administration of Insulin/ByettaHypoglycaemia MXDiabetes and DrivingAlcohol and DiabetesSteroids and DiabetesScreeningDiabetes and Foot Care
Other

Comments

Ongoing Education Needs

 

Follow up

Follow up in Alfred Diabetes Clinic required*

Date of Follow Up

 

Assessment/Care Plan

Please tick below if you have an Assessment and/or Care Plan and would be happy for Star Health to contact you to obtain a copy. Alternatively, you can attach them below.
AssessmentCare Plan
 
Please attach an Assessment and/or a Care Plan if available

Please attach Diabetes Injectable Medication Referral form if applicable

Does the client give consent to a referral to Star Health?*

 

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