OFFICIAL: Sensitive//Medical in confidence

SALHN GP PLUS DIABETES OUT OF HOSPITAL REFERRAL

Facility/Site: ……………………………………………………....	

SA Health UR No:...........................................…………..........

  Surname:  <PtSurname>

  Given Name: <PtFirstName>

  Second Given Name: <PtMidName>

   D.O.B: <PtDoB>   Sex/Gender: <PtSex>	

Referrals to be faxed to Fax: (08) 8164 9199	          Enquiries can be directed to Phone: (08) 8164 9111 (opt 1) 

	
REFERRAL TO

	
  Diabetes Nurse Educator	
	
  Diabetes Dietician	

	
	
REFERRER INFORMATION
	
Referrer’s Name:	<DrName>	Position / Discipline:	<DrProviderNo>	
Practice Name / Department:	<Practice>	Practice Phone:	<LocationPhone>	
Referrer Address:	<LocationAddress>
	
Referrers Email:	<LocationEmail>	Date:	<TodaysDate>	
Patient consent to referral:	
Yes	

No	

			
		
GENERAL PRACTITIONER DETAILS (if not referrer)
	
Doctor’s name:
	<DrName>	Surgery name:	<Practice>	
Surgery address:
	<LocationAddress>	
Practice Phone:
	<LocationPhone>	Practice Fax:	<LocationFax>	
		
PATIENT DETAILS
	
Address (or address where care will be provided for home visiting)
	<PtStreet>	
Preferred phone:
	<PtPhoneMob>	Alternative phone:	<PtPhoneH>	
Medicare number:
	<PtMCNo>	Expiry date:	<PtMCExpiry>	
Is the patient of 
Aboriginal or Torres Straight Islander origin?	<PtATSI>	
Is an interpreter 
required?	<Interpreter Required?>	Language:	<PtLanguage Spoken>	
Does the patient have a carer?	

  Yes	

  No	

	Relationship to patient:		
Carer Name:		Phone Number:		
Existing or new services	
	
  NDIS	

  Home Care Package	

  RDNS	

	

	

	

  MRU	

  Other	

	

Details:

	
Other considerations & patient requirements 
	Eg. Visually impaired, literacy level, social situation

	
	
REFERRAL INFORMATION
	
Type of Diabetes:

  Type 1	

  Type 2	

  Type 3C	

	
  Corticosteroid Induced	

  Other _________________________________	

Years of diagnosis: 

* Reason for referral:	

  New or suspected diagnosis of Type 1 Diabetes /LADA	

	

  New diagnosis of Type 3c Diabetes	

	

  Severe hypoglycaemia (requiring the assistance of a 3rd party to treat)	

	

  Recurrent hypoglycaemia	

	

  Recent admission for Diabetes Ketoacidosis (DKA)	

	

  Recent admission for hyperosmolar hyperglycaemic state (HHS)	

	

  Recent unexplained hyperglycaemia > 20mmol/L > 7 days	

	

  Urgent insulin titration for corticosteroid therapy	

	

  Pump failure without alternative plan in place	

	

  Recent hospitalisation without inpatient Endocrine review	

	

or	

	

	
  Other	

	
* Details of referral:

Past medical history:
	<PMHActive>	
Current medications
(Including GLP1s, Oral Hypoglycaemics)

	<CurrentRx>
	
If on Insulin please 
provide name, dose, frequency and route

	
  Insulin Start	

  Insulin Change	

  Existing	

Details:

	
  ICR	

  ISF	

	
Titration Order	Permission to Titrate Insulin according to SALHN standing orders:

  Yes	

  No	

	
Instructions regarding other oral or injectable diabetes medications	
	
* Pathology
	(Attachments to be included with referral):

	
  HbA1c	

	

  If HbA1c is not provided, reason:_____________________________________________	

	

  For newly diagnosed Type 2 Diabetes, diagnostic pathology to be included	

	

  Other (i.e. Biochem, including renal function, lipids): _____________________________	

	
If currently an Inpatient planned discharge date
	Please only submit when patient is discharged home or to place of residence

Date:	________________________________

Please attach any relevant results, pathology, medication and past medical history
* To enable this form to be actioned please ensure the following mandatory fields have been completed	

OFFICIAL: Sensitive//Medical in confidence