Download Please do not refer patients who fall within thefollowing categories to

Croydon Community
Diabetes Service Referral
Form
Tel. No. 01689865911
www.bromleyhealthcare.org.uk
Please do not refer patients who fall within thefollowing categories to this service:
Refer directly to secondary care for:
ACUTE EMERGENCY AND URGENT REFERRALS
Acute Type 1
Under 19 years
On dialysis
Pregnancy or pre pregnancy
Patients using continuous subcutaneous insulin infusion (CSII)
Patients with a foot ulcer/suspected Charcot/new foot problem(Refer to Vascular or Podiatry services as appropriate)
Patients with diabetes in CKD 3+ Proteinuria, Deteriorating CKD3 or CKD 4& 5
For the services below please complete a separate referral Form to be found on the CReSS website.
Retinal Screening
Podiatry
------------------------------------------------------------------------------------------------------------------------- --------All other referrals for Diabetes Management, Dietetic support and education including Stable CDK3 without
ProteinuriarequiringGlycaemic support should be referred to the Croydon Community Diabetes Service using
this form.
ALL INFORMATION TO BE COMPLETED FULLY
1.Community Referral Information
Diabetes(Adults 19 years and above)
Type 1
Type 2
Other
Education ( Type 2)
Dietitian
Psychology
Education ( Type 1)Date of Diagnosis …………………………………… (essential information)
All (non-urgent) Diabetes Referrals should be forwarded to Bromley Healthcare where they are triaged and
referred on as appropriate.
3. Patient Details
Title: «PATIENT_Title»
First Name:
«PATIENT_Forename1»
NHS Number:
«PATIENT_New_Format_NHS_Number»
Surname: «PATIENT_Surname»
Date of Birth:
«PATIENT_Date_of_Birth»
Gender:
«PATIENT_Sex»
Age:
Address: «PATIENT_House» «PATIENT_Road» «PATIENT_Locality» «PATIENT_Town» «PATIENT_County»
«PATIENT_Postcode»
Telephone:
(Home) «PATIENT_Main_Comm_No»
(Mobile) «PATIENT_Mobile_No»
Ethnicity:
4. Next of Kin Details- (optional)
Title:
First Name:
Surname:
Address (If different to patient's):
Telephone:
(Home)
(Mobile)
Relationship to Patient:
5. Carer Details (If different to Next of Kin)
Title:
First Name:
Address (If different to patient's):
Telephone:
(Home)
(Mobile)
Surname:
Relationship to Patient:
5. Referral Details
Date of Referral
Form Completed By: «REFERRAL_Clinician»
«REFERRAL_Event_Date»
Referring Clinician(If form completed on their
behalf):
Profession:
GP
Practice Nurse
Other (Please state)
Surgery: «PRACTICE_Name»
National Practice Code: H83014
Address: «PRACTICE_BlockAddress»
Telephone:
«PRACTICE_Main_Comm_No»
Email:
Fax: «PRACTICE_Fax_No»
6.Reason for Referral/Diagnosis
Please indicate the patient’s current problem(s), date of diagnosis and your expectation of the result of the referral to the service.
Please provide as much detail as possible. Alternatively you may wish to attach (or insert at section 9) a letter or summary of
relevant and explanatory consultations from the medical record.
7. Help Us to Help Your Patient
Please advise of any known hazard/ access issues:
Joint visits with DNs can be arranged if required
Patient/carer prefers language other than English. State language:
and dialect (if applicable):
Patient requires additional support for:
Sensory Impairment
Learning Disability
Cognitive Deficit / Dementia
How might the service best meet these needs?
9. Further Information
Please type/paste/merge further information below. Any pre-merged information which is irrelevant to the
referral should be removed.
CONSULTATIONS:
ALL INFORMATION BELOW IS ESSENTIAL UNLESS OTHERWISE NOTED
Medical History «MEDICAL_HISTORY»
«REPEATS»
«DRUG_ALLERGY»
Recent Investigations
Height «PATIENT_Height»
Weight «PATIENT_Weight»
BMI «PATIENT_BMI»
BP «PATIENT_BP»
Biochemistry
Random Blood Sugar:
Fasting Glucose
HbA1cwithin last three months (DCCT)
HbA1c (DCCT):
Serum Cholesterol: «PATIENT_Total_Cholesterol»
Serum HDL: «PATIENT_HDL»
Serum LDL: «PATIENT_LDL»
Serum Triglicerides: «PATIENT_Triglycerides»
Serum Sodium:
Serum Creatinine:
Glomerular Filtration Rate (non-Afro Caribbean):
Glomerular Filtration Rate (Afro Caribbean):
Serum Potassium:
Urine Albumin:Creatinine ratio:
Urine Protein:Creatinine ratio:
Serum Total Bilirubin:
Serum ALP:
Serum AST:
Serum TSH (if available):
Serum Free T4 (if available):
Haematology
Serum Haemoglobin:
Mean Corpuscular Volume (MCV
Serum Ferritin (if available):
Serum Folate (if available):
Serum Vitamin B12 (if available):