Download Referral Form

Referring Physician Contact Information
General Internal Medicine Diabetes Clinic
100 West 5th Street, Hamilton, Ontario
Phone: (905) 522-1155 Ext.32045 / Fax: (905) 521-6128
Gestational Diabetes Referral Form
The information you provide is vital to the selection
of the correct management for your patient. PLEASE PRINT
Date of Request: ________________________________
Patient Name: ________________________________________________________________________________________________________
Last
First
Middle
Address _____________________________________________________City: ________________________ Postal Code: ________________
Apt.
Phone (H): (________)____________________________
Phone (W): ( ________)_______________________________
DOB:____________________________________ Age: _________ Sex: _________ Weight:_____________ kg/ lbs
YYYY
MM
DD
ODSB 
HIN:________________________________________ Version: ____________
NIHB 
NOTE: PLEASE SPECIFY ANY SPECIAL NEEDS
Reason for Referral (Check all that apply)
Language/communication barriers?
NO
YES
Education Class and Referral to Endocrinologist (Recommended for GDM)
Specify:___________________________________________
Education Class Only (Recommended for IGT)
If indicated an individual appt will be scheduled instead of
Other Endocrine:____________________________________( please specify)
class.
Other: ____________________________________________
Diabetes History
Co-morbid Conditions
Heart Disease
Gestational
Hypertension
Renal Impairment/Proteinuria
____# OF WEEKS PREG
Pregnancy Complications:________________________________________________________________
Current Medications:
LABS:
COMMENTS/OTHER PERTINENT HISTORY:
GTT:
o
50g: 1hr________________
o
75g: FBS__________1hr__________2hr__________
______________________________________________________
______________________________________________________
______________________________________________________
Due Date:______________________________
______________________________________________________
Requesting Physician: X _________________________________
Specialty: ______________________________________
Signature: X ________________________________________________
OHIP Billing #: _______________________________________
Family Physician: ____________________________________________