Diabetes Tasmania Statewide Clinical Services Referral Form	
Phone: 6215 9000 I Fax: 6215 9099 I HealthLink EDI: diabetas
Referral Date: <<Miscellaneous:Date>>
Referrer Details
Doctor name: <<Doctor:Name>>
Practice name: <<Practice/Location:Name>>
Practice address: <<Doctor:Address Line 1>>, <<Doctor:City>>, <<Doctor:Postcode>>		Provider number: <<Doctor:Provider Number>>
Phone: <<Doctor:Phone>>
Fax: <<Doctor:Fax>>	

Patient Details (Consent for contact: <<Patient consent for referral to these services?>>)
Name: <<Patient Demographics:Full Name>>
Date of Birth: <<Patient Demographics:DOB>>
Gender: <<Patient Demographics:Gender>>
Address: <<Patient Demographics:Address Line 1>>, <<Patient Demographics:City>>, <<Patient Demographics:Postcode>>
Phone: <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
Email: <<Patient Demographics:E-mail>>
Referral discussed with patient: <<Referral discussed with patient?>>
Preferred contact: <<Preferred contact method?>>
Ok to leave message: <<Ok to leave a message?>>		Ethnicity: <<Patient Demographics:Ethnicity>>
ATSI: <<Patient Demographics:ATSI>>
Language Spoken: <<Language spoken?>>
Medicare Number: <<Patient Demographics:Medicare Number>>
DVA Number: <<Patient Demographics:DVA Number>>
Interpreter required: <<Interpreter required?>>
Diabetes Diagnosis: <<Diabetes Diagnosis?>>
Years diagnosed: <<Years diagnosed?>>	

How we manage appointments
A Diabetes Tasmania health professional will discuss this referral with the patient prior to booking an appointment. To manage our services effectively appointments are triaged based on pathology, treatment and other information provided in this referral. Referral cannot be progressed without this information. 	

About our services
Individual appointments are available with a diabetes educator, dietitian, nurse practitioner, and social worker as needed, for adults with:
•	type 2 diabetes or at high risk of diabetes
•	type 1 diabetes diagnosed over 12 months and not using an insulin pump
The COACH Program: Six month telephone based program focused on achieving risk factor targets.
DESMOND group education: A one day self-management group program covering the basics of diabetes, monitoring, complications and goal setting. 
SMART programs: A series of 3 hour topic specific diabetes group programs – ShopSmart, CarbSmart, MedSmart and FootSmart. 	

Describe current needs or goals of care
<<Describe current needs or goals of care>>	

Injectable medication commencement
GLP1 type:	

Insulin Type:	
	
Dose:	
	
Frequency:	

Insulin Type:	
	
Dose:	
	
Frequency:	

	

Allergies and intolerances
<<Clinical Details:Allergies/Adverse Reactions>>	

Current and past medical history
<<Clinical Details:History List>>	

Current medications
<<Clinical Details:Medication List>>	

Smoking status
<<Clinical Details:Smoking>>	

Please attach relevant pathology: Eg. OGTT HbA1c Total Chol HDL LDL Triglycerides Vitamin D TFT  FBC Micro alb. 
<<Summary:Investigation Results (Selected)>>