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.

URGENT referral: <Urgent?>	(Urgent referrals will attempt to be seen within 7 days)	
Client Details	
Title: <PtTitle>	Surname: <PtSurname>	Given names: <PtFirstName> <PtMidName>	
Address: <PtStreet>, <PtCity>, <PtState>	Postcode: <PtPostcode>	
DOB: <PtDoB>	Gender: <GenderIdentity> Birth Sex: <PtSex>	Ethnicity: <PtEthnicity>	
Telephone: <PtPhoneH>	Mob: <PtPhoneMob>	Email: <PtEmail>	
Medicare Number: <PtMCNo>	Reference No: <PtMCLine>	Expiry Date: <PtMCExpiry>	
Interpreter Required:	<PtInterpreter>	Language: <PtPrefLang>	
Referred By: 	Date Referral Sent: <TodaysDate>	
Title:	Surname: <UsrSurname>	Given Names: <UsrFirstName>	
Agency Name: <Practice>	Address: <UsrAddress>	Postcode:	
Telephone: <UsrPhone>	Email: <PracEmail>	Facsimile: <UsrFax>	
Future correspondence to be sent to:	
Name: <Future Correspondence To (if not usual GP)>	Email: <Future Correspondence Email>	Fax: <Future Correspondence Fax>	
Diabetes Type <Diabetes Type>	
NDSS Registration:	<NDSS Registration>	Date of Diagnosis: <Date of Diagnosis>	Urgent Referral: <Urgent?>	
Reason for Referral: <Reason for Referral>
	
Medications Profile Attached?  (If yes, list with dosage, frequency & route)	
<Patient-Medications-Attached-(else-supply)>	
Referred by Diabetes Connect consult:	<Referred by Diabetes Connect?>	
Pathology: Copies Attached: <Pathology Attached?> Else complete below.	

Medical History	
<Medical-History>

Allergies / Reactions	
<Reactions>
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

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

Insulin Therapy Titration Form: 

Insulin Requiring - Does the client use Insulin? <Does this client require insulin?>	
Insulin Therapy Order (List Insulin type and starting dosage below)	
Insulin Type/s	Dose & Time	
<Long-Acting-Insulin-Type> 	<Long-Acting-Dose-and-Time>	
<Short-Acting-Insulin-Type>	<Short-Acting-Dose-and-Time>	
<Mixed-Insulin>	<Mixed-Insulin-Dose-and-Time>	
As this Patient’s Medical Officer - <Authorise-Diabetes-WA-CDE-to-Titrate-Clients-Insulin>	
By completing this form, 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. 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 pre-prandial).	Higher Range Clinically Appropriate
Target 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)
HbA1C 6.5% or less
Time in Range if applicable (3.5-7.8mmol/L): >70%
Gestational Diabetes (ADIPS)
Fasting:  4.0 - 5.2mmol/L  
2 hrs Post Prandial  4.0 - 6.7mmol/L 
Time in Range if applicable (3.5-7.8mmol/L): >90%
Type 2 in Pregnancy (ADIPS)
Fasting:  4.0 - 5.3mmol/L  
2 hrs Post Prandial  4.0 - 6.7mmol/L
Time in Range if applicable (3.5-7.8mmol/L): >80%	
Changes Required to Oral / Injectable Therapy:	
  <Changes-to-Glucose-Lowering-Agents>	
Medical Officer	
Title: 	Given Name/s: <UsrFirstName>	Surname: <UsrSurname>	
Practice Name: <LocationName>	
Address: <LocationAddress>	
Phone: <LocationPhone>	Fax: <LocationFax>	Email: <LocationEmail>	
•	This insulin therapy order is valid from the below date.
•	The order becomes invalid if there is a change in the patient’s medical officer, a change in insulin management, 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.
Signature:                                                                                          Date: <TodaysDate>	
Please return to:
Healthlink: DWATEL3H | Fax: (08) 9221 1183
Country WA Email:telehealth@diabeteswa.com.au | Perth Metro Email: clinic@diabeteswa.com.au 

Endocrinology Registrars Available

To discuss the diabetes medical management of your patient or you have an urgent matter, contact an endocrinology registrar 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	

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 Information
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/management-of-type-2-diabetes/introduction
Appendix G. Types of Insulin Available
	https://www.racgp.org.au/FSDEDEV/media/documents/Clinical%20Resources/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/management-of-type-2-diabetes/appendices/appendix-2-guide-to-insulin-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.