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: Miscellaneous.Date Feedback Requested:  Yes

Referral to: Diabetes Referral Centre Tel:  03 4215 1390 Fax: 03 4215 1383 Service requested: Service Requested Urgency: Urgency Referral valid for: Refer valid for | | Referring General Practitioner: Treating Doctor.Name Address: Practice.Address HPI-O: Ph: Practice.Phone Fax: Practice.Fax Provider No.: Treating Doctor.Provider Number HPI-I:

Consumer details:
Name: Patient Demographics.Full Name
Date of Birth:.Patient Demographics.DOB
Age:.Patient Demographics.Age
Sex: Patient Demographics.Gender
Title: Patient Demographics.Title
Pt IHI: Patient Demographics.IHI Number
ATSI:   Patient Demographics.ATSI Status

Contact Address:
Patient Demographics.Full Name
Patient Demographics.Full Address
Tel (H): Patient Demographics.Phone (Home)
Tel (M): Patient Demographics.Phone (Mobile)
Email: Patient Demographics.E-mail
Alternative Contact:

Interpreter required: Interpreter required | | DVA Number: Patient Demographics.DVA Number
Preferred language is: Interpreter language | | Medicare Number: Patient Demographics.Medicare Number
Pension Card Number: Patient Demographics.Pension Number | | Private Health Insurance:Patient Demographics.Health Fund Member Number

Date patient consented to referral:  Miscellaneous.Date
Consent to share information:  Share information
Consent to MBS bulk billing clinic if available:  MBS Clinic

WestVic HealthPathways provides guidance in patient assessment, management and referral.
HealthPathways

CLINICAL INFORMATION

Please consider Telehealth for this patient:  Telehealth option

Reason for patient referral: 
Referral reason

General Diabetic Complications General Diabetes |
Diabetic nephropathy: Diabetic Nephropathy | Worsening renal function: Renal Function
Retinopathy:  Retinopathy | CVA: CVA
IHD: IHD | Severe hypo: Severe hypo
Diabetic Foot Complications/ Ulcers Diabetic Foot |
Peripheral neuropathy: Peripheral Neuropath | Peripheral vascular disease: Peripheral vascular
Evidence of osteomyelitis: Osteomyelitis | Previous amputations: Previous amputations
Chronic ulcer : Chronic ulcer | Acute ulcer: Acute ulcer
Resistant organism/Complex microbiology: Resistant organsim | Signs of soft tissue infection: Signs of soft tissue
Charcot foot: Charcot foot | If pt has signs of sepsis, refer to ED:( Sepsis)

Previous relevant consultants or other Health Professionals involved in Mx of problem or related problem:
Previous consultant

Other Health Professionals involved | Date of last visit
Optometrist or Ohpth | Date Optometry/optha
Diab Edu | Date Diab Educator
Dietician | Date dietitian
Podiatrist | Date podiatrist

Recent PHx Medication list review undertaken: 
Review PHx meds

Warnings: Clinical Details.Warnings
Allergies: Clinical Details.Allergies

Current Medication:
Clinical Details.Medications - Current Regular

Social History:
Clinical Details.Social History
Clinical Details.Smoking
if yes to smoking, has cessation program been discussed?:  Smoking cessation

Past Medical History: 
Clinical Details.Problem List (Resolved) With Comments

Current Medical History:
Clinical Details.Problem List (Current) With Comments

Investigation Results:
HbA1c, lipids, ACR, 
Clinical Details.Result List (Selected)

GP referral:  Treating Doctor.Name, Miscellaneous.Date Pt:Patient Demographics.Full Name DOB:Patient Demographics.DOB 	page