Download Please complete this form in full and EMAIL to clcht.mertonspa@nhs

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: