Please return completed forms to Diabetes WA:
Fax: (08) 9221 1183 | Email: telehealth@diabeteswa.com.au| Phone: (08) 9436 6280  |  Healthlink ID: DWATEL3H

Date <TodaysDate>

The Endocrinologist 
Diabetes Telehealth Endocrinology Service 
Diabetes WA 
Level 3, 322 Hay Street 
Subiaco 6008 

Dear Doctor,

Thank you for seeing the below patient for review:

Patient Name: <PtFullName>

Contact Number: <PtPhoneMob> / <PtPhoneH>

Date of Birth: <PtDoB>

Medicare Number: <PtMCNo> <PtMCLine> Exp: <PtMCExpiry>

Address: <PtAddress>

Reason for Referral or any additional comments: - 

Medications:

<CurrentRx>

Past History:

<PMHActive>

Pathology Results:

<Atoms>

Patient to be reviewed by a Diabetes Telehealth Diabetes Educator? <Patient to be reviewed by Diabetes Educator?>

Kind regards,

<UsrName>
<UsrQualifications>