The Diabetes Telehealth Services is delivered by Diabetes WA in partnership with WA Country Health Services and WA Primary Health Alliance

Diabetes WA Referral Form
IMPORTANT NOTICE: The information contained in this document is confidential. If you receive this message in error, please notify us immediately and return the original message to Diabetes WA.
MY HEALTH RECORD: The Diabetes WA Clinic accesses My Health Record prior to and during appointments. If the client does not consent, please contact us at least 1 business day before the appointment.
MEDICARE REBATE (METRO ONLY): If patient is eligible for Medicare Rebates under GPCCMP, please attach to this referral.
Please tick YES if this is an URGENT referral: YES	NO	(Urgent referrals will attempt to be seen within 7 days)	
Client Details (please complete ALL sections)	
URN:	Registered with Health Navigator:	Yes	No	
UMRN:	Site:	
Title:	Surname:	Given names:	
Address:	Postcode:	
DOB:	Gender:	Aboriginal/TSI:	Yes	No	
Telephone:	Mob:	Email:	
Medicare Number:	Reference No:	Expiry Date:	
Interpreter Required:	Yes	No	Language:	
Referred By:	Date Referral Sent:	
Title:	Surname:	Given Names:	
Agency Name:	Address:	Postcode:	
Telephone:	Email:	Facsimile:	
Future correspondence to be sent to:	
Name:	Email:	Facsimile:	
General Practitioner Details	GP Aware of Referral:	Yes	No	
Title: Dr	Surname:	Given Names:	
Practice Name:	Address:	Postcode:	
Telephone:	Email:	Facsimile:	
Diabetes Type (Please check)	
Type 1	Type 2	Gestational	Other:	Date of Diagnosis:	
NDSS Registration:	Yes	No	NDSS No:	Urgent Referral:	Yes	No	
Reason for Referral:	
Medications:	Yes	No (If yes, list with dosage, frequency & route)	
	
Referred by Diabetes Connect consult:	Yes	No	
Pathology: Copies Attached	Yes	No (Please indicate results and date)	
Weight (kg):	HbA1c (mmol/mol or %):	LDL-C (mmol/L):	
Height (cm):	Total Chol (mmol/L):	Micro albuminuria (mg/L):	
BMI:	Triglycerides (mmol/L):	ACR (mg/mmol/L):	
BP (mmHg):	HDL-C (mmol/L):	eGFR (ml/min/1.73m2):	
Medical Conditions:	Yes	No (Please check boxes below)	
MI
Hyperlipidaemia Dialysis Glaucoma
Immune Condition	CHF	Angina	Hypertension
CVA	PVD	Nephropathy
Neuropathy	Retinopathy	Cataracts
COPD	Asthma	Hypo/Hyperthyroidism
Dementia	Cancer	Mental Health Condition	
Other (please list)	
Surgical History:	Yes	No	CABG	Stent (heart)	Stent (leg)	Other:	
Allergies/Alerts:	Yes	No	Allergy details:	
For more information, please contact:
Healthlink: DWATEL3H | Telephone referrals: 1300 001 880 | Fax referrals: (08) 9221 1183
| Country WA Email:telehealth@diabeteswa.com.au | Perth Metro Email: clinic@diabeteswa.com.au | Level 3/322 Hay Street Subiaco, WA 6008