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

Insulin Therapy Titration Form

Patient	
DOB:	Given name/s:	Surname:	
Address:	Diabetes Type:	
Insulin Theapy Order (List Insulin type and starting dosage below)	
Insulin Type/s	Dose & timing	

		
As this Patient’s Medical Officer:	
I authorise a credentialled diabetes educator at Diabetes WA to adjust Insulin doses via in-person, video conference and/or telephone consultations according to the adjustments and blood glucose targets listed below.
Size of Incremental Adjustments: 2 units every 3 days.
Exceptions: Ryzodeg - 1-2 units weekly. Toujeo - 1 unit daily or 10% of dose.	
Target Glucose Range / Size of Incremental Adjustments	
Type 1 & 2 Diabetes
Fasting:
4.0 to 6.0 mmol/L
2 hrs Post Prandial
5.0 to 10.0 mmol/L (rise of < 2-3 from preprandial).	Higher Range Clinically Appropriate
Targer range:
6.0 to 15.0 mmol/L
As clinically appropriate.
Adjusted based on individual needs or symptoms and risk of hypoglycaemia.	Pre-Pregnancy (ADIPS)
Time in Range (3.5-7.8mmol/L): >70% HbA1C 6.5% or less
Gestational Diabetes (ADIPS)
Fasting: 4.0 - 5.2mmol/L
2 hrs Post Prandial 4.0 - 6.7mmol/L
Type 2 in Pregnancy (ADIPS)
Fasting: 4.0 - 5.3mmol/L
2 hrs Post Prandial 4.0 - 6.7mmol/L	
Changes Required to Oral / Injectable Therapy:	
	
Medical Officer	
Title:	Given Name/s:	Surname:	
Practice Name/Address:	
Phone:	Fax:	Email:	
This insulin therapy order is valid from date of signature, and becomes invalid if there is a change in insulin
management, a change to the clients medical officer or at the request of the medical officer.
Diabetes WA is not a 24-hour service and therefore cannot provide urgent medical assistance to patients.	
GP Signature:	Date:	

Please return to:

Fax: (08) 9221 1183
Phone: 1300 001 880

Metro (email): clinic@diabeteswa.com.au Country (email): telehealth@diabeteswa.com.au

Healthlink ID: DWATEL3H

Endocrinology Registrars Available

If you wish to discuss the diabetes medical management of your patient or you have an urgent matter, an endocrinology registrar can be contacted 24 hours, 7 days a week at the following tertiary hospitals:	
Fiona Stanley Hospital	6152 2222	
Royal Perth Hospital	6477 5213	
Sir Charles Gardiner Hospital	6457 3333	
Other	
Diabetes Connect	Call Diabetes WA Consultant Endocrinologist, or to book a Multidisciplinary Case Conference - 08 9436 6270
https://www.diabeteswa.com.au/diabetes-connect/	
Links for Clinical Support or Useful Infomation	
Health Pathways	https://www.communityhealthpathways.org/	
RACGP General Practice Management of Type 2 Diabetes	https://www.racgp.org.au/clinical-resources/clinical-guidelines/ key-racgp-guidelines/view-all-racgp-guidelines/manage-ment-of-type-2-diabetes/introduction	
Appendix G. Types of Insulin Available	https://www.racgp.org.au/FSDEDEV/media/documents/Clinical%20 Resources/Guidelines/Diabetes/Appendix-G.pdf	
Appendix H. Examples for Insulin Initiation and Titration	https://www.racgp.org.au/clinical-resources/clinical-guidelines/ key-racgp-guidelines/view-all-racgp-guidelines/manage-
ment-of-type-2-diabetes/appendices/appendix-2-guide-to-insu-
lin-initiation-and-titrati	
NDSS Health Professional Portal to Register and Change in Medication	https://hp-portal.ndss.com.au/SignIn	
Other factors you may wish to consider prior to initiation of insulin:	Patient competency – consider vision or hearing impairment, poor dexterity, cognitive impairment.
Preferably commence insulin at the beginning of the week to ensure the patient can access health professional support as required. Once commenced on insulin, encourage regular review. Encourage patients to include a support person in education in case of emergency.
Develop with your patient a Sick Day Plan including hypoglycaemia treatment.