Victorian Statewide Referral Form	General Practice version Jul 2019

REQUEST FOR DIABETES REFERRAL CENTRE APPOINTMENT - FAX 03 4215 1383 OR
								      - E-REFER USING REFERRAL NET

GP Referral | | Referral Date: <TodaysDate> Feedback Requested:  Yes

Referral to: Diabetes Referral Centre (DRC) Tel:  03 4215 1390 Fax:  03 4215 1383 Service requested: <Service Requested:> Urgency:  <Urgency> Referral valid for:  <Referral valid for:> | | Referring General Practitioner: <DrName> <Practice> <UsrAddress> HPI-O: <PracHPIO> Phone: <UsrPhone>   Fax: <UsrFax> Email: <DrEmail> Provider No.: <DrProviderNo> Dr HPI-I:<DrHPII>

Consumer details:
Name:	<PtFirstName> <PtSurname>
Date of Birth:	<PtDoB>
Age:                        <PtAge>
Preferred Name/s:	<PtPrefName>
Sex:	<PtSex>
Ethnicity:               <PtEthnicity>
Title:	<PtTitle>
Pt IHI:                     <PtIHI>

Contact Address:	<PtName>
	<PtStreet>
	<PtCity>  <PtState>    <PtPostcode>
Phone:	<PtPhoneH>
Work:	<PtPhoneWk>
Mobile:	<PtPhoneMob>
Email:	<PtEmail>

Alternative Contact:

Interpreter required: <Does the patient require an interpreter?> | | DVA Number: <PtDVANo>
Preferred language is: <If interpreter needed, which language> | | Insurance: <PtHealthIns>
Pension Card Number: <PtPensionNo> | | Medicare Number: <PtMCNo>

Date patient consented to referral:  <FormattedDate>
Consent to share information:  <Consent to share information>
Patient consents to MBS bulk billing clinic if available:  <Consent to MBS bulk billing clinic>

Please consider telehealth for this patient:  <Please consider telehealth for this patient>

Reason for patient referral: 
<Reason for Referral>
General Diabetes Complications <General Diabetes Complications?> |
Diabetic nephropathy:  <Diabetic nephropathy?> | Worsening renal function:  <Worsening renal function?>
Retinopathy:  <Retinopathy?> | IHD: <IHD?>
CVA:  <CVA?> | Severe hypo:  <Severe hypo?>
Diabetic Foot Complications/ Ulcers <Diabetic Foot Complications / Ulcers?> |
Peripheral neuropathy: <Peripheral neuropathy?> | Peripheral vascular disease: <Peripheral vascular disease>
Evidence of Osteomyelitis: <Evidence of osteomyelitis> | Previous amputations: <Previous amputations>
Chronic Ulcer: <Chronic ulcer> | Acute Ulcer: <Acute ulcer>
Signs of soft tissue infection:<Signs of soft tissue infection - cellulitis, pus etc> | Resistant organism/complex microbiology: <Resistant organism/complex microbiology>
<If the patient has signs of sepsis, refer to ED> | Charcot Foot:   <Charcot Foot?>

Previous relevant consultants or unit involved in Mx of problem or related problem:
<Previous consultant/s involved in Mx of problem>

Is the patient also seeing: | Date of last appointment
Diabetes Educator: <Is the patient also seeing a Diabetes Educator?> | <Date of last visit to diabetes educator>
Dietician: <Is the patient also seeing a Dietitian?> | <Date of last visit to dietitian>
Podiatrist:  <Is the patient also seeing a Podiatrist?> | <Date of last visit to podiatist>
Optometrist/Ophthalmologist: <Is the patient also seeing an Optometrist/Ophthalmologist ?> | <Date of last optometry/ophthalmology visit>

Warnings:  <Comment>
Allergies:   <Reactions>

Current Medication:
<RegularRx>

Past Medical History: 
<PMHAll>

Smoking:  <SmkHx>  If smoker, smoking cessation discussed:  <If smoker, smoking cessation discussed?>                 
Alcohol History:  <AlcHx>

Progress Notes: 
<Visits>

Investigation Results:
<Please include HbA1c, lipids, ACR, UEs>
<Ix>

 Patient: <PtName>,DoB:<PtDoB>

GP Referral:  <DrName>,  Patient: <PtName>,DoB:<PtDoB>      DoReferral:<TodaysDate> 	Page