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ADULT INTERMEDIATE DIABETES SPECIALIST TEAM REFERRAL FORM URGENT or Tier 4 referrals (e.g. Type 1 diabetes, pregnant, <25 yrs, insulin pumps, CKD 4 & 5) DO NOT USE THIS FORM Contact the Diabetes Centres at St Helier Hospital (020 8296 2563) or St George’s Hospital (020 8725 1429) or Medical On Call. Newly diagnosed Type 2 diabetes suitable for group education Download the DESMOND referral form from our website http://www.clch.nhs.uk/media/225614/diabetes_service__desmond_group_education_referral_form.doc and email or fax to the SPA (see below) Diabetic Eye Screening Programme (DESP) Download the DESP referral form http://www.smcs.nhs.uk/referral-forms.asp and email or fax to the admin centre EMERGENCY diabetes podiatry referral For ST GEORGE’S: Call Diabetic Foot Clinic on 020 8725 2753 For ST HELIER: Download the emergency diabetes podiatry referral form. Call St Helier podiatry on 020 8296 2111 then Fax to 020 8296 2731 Please complete this form in full and EMAIL to [email protected] or FAX to 0300 008 2122. Incomplete forms will be returned and may cause delay. PATIENT’S DETAILS Title: M F Forename(s): Surname(s): NHS Number: D.O.B: Housebound Patient?: YES NO YES NO Address (incl. postcode): Daytime contact number: Alternative contact number: Does the patient have a learning disability? White British White Irish Any other White Mixed: White/Black Caribbean Mixed: White & Black African Mixed: White & Asian YES NO Transport required (to be organised by GP)? ETHNICITY Any other mixed background Chinese Asian or Asian British Indian Asian or Asian British Bangladeshi Asian or Asian British Pakistani Any other Asian background REFERRER DETAILS GP Details Black/Black British Caribbean Black or Black British African Any other Black groups Any other ethnic group Declined to state ethnicity Interpreter required? YES NO Referrer details if not GP Date of referral: Date of referral: GP Name: Name of referrer: Job title: Surgery address: (mandatory) Location: Contact number: Fax number: NHS.net email address: Contact number: Fax number: Email address (safe to send patient information): Reasons for Referral Please choose all that apply: Type 2 diabetes to initiate insulin therapy Type 2 diabetes to initiate GLP-1 agonist therapy Unsatisfactory blood glucose control Hypoglycaemia unawareness Recurrent hypoglycaemia Peripheral neuropathy Dietetic assessment Drivers – vocational licence Pre-conception management Diabetes support following discharge from hospital Type 1 diabetes requiring education Newly diagnosed Type 2 diabetes NOT suitable for group education Other (please write) _____________________________ ADULT INTERMEDIATE DIABETES SPECIALIST TEAM REFERRAL FORM HISTORY AND INVESTIGATIONS All fields must be completed Date of diagnosis of diabetes: Patient’s Name: Type of diabetes (if known): Type 1 / Type 2 / other Please attach patient summary and current medication OR List Active Problems, Past Medical History and Medications below Measurements Results Date Height (cm) Weight (kg) BMI (kg/m²) Blood pressure (mm/Hg) Urine Protein Urine Ketones HbA1c (mmol/mol) Serum creatinine (umol/l) eGFR (ml/min) Total cholesterol (mmol/L) LDL cholesterol (mmol/L) HDL cholesterol (mmol/l) Triglycerides (mmol/L) Urine albumin/creatinine For office use only: Duration (circle): Appointment in Tier 3 Consultant Specialist GP DSN Dietitian New 30 min/ FU 20 min New 30 min/ FU 20 min 30 / 60 mins 30 / 60 mins Location: Triage by: Name: Signed: Date: