Prince of Wales Hospital Diabetes Centre

FAX TO: 9382 4612
PHONE ENQUIRIES TO: 9382 4600	

REFERRAL DATE: <TodaysDate>

PREFERRED CLINIC                                                    	RELEVANT MEDICAL HISTORY	
		
	Diabetes Clinic		Retinopathy	
	Type 1 Diabetes Clinic		Foot Ulcer	
	Podiatry: High Level &Complex Diabetic Foot Care(Please also send referral Podiatry: High Level form)		Hyperlipidaemia	
	Dietician		Obesity	
	Diabetes Education		Hypertension	
			Neuropathy	
			Renal Disease	
			Vascular Disease	
			Other:

	

REASON FOR REFERRAL (Mandatory For ALL Referrals)
<Reason for referral>	TYPE OF DIABETES:
<Specify type of Diabetes:>	

REFERRING DOCTOR
NAME: <DrName>	PROVIDER	<DrProviderNo>	
ADDRESS:
<DrAddress>	PHONE
FAX
EMAIL	<DrPhone>
<DrFax>
<DrEmail>	

PATIENT INFORMATION
NAME: <PtName>	GENDER :  <PtSex>  	
COUNTRY OF BIRTH: <PtCountry of Birth>	DATE OF BIRTH: <PtDoB>	
ADDRESS
<PtAddress>	HOME: <PtPhoneH>	

WORK: <PtPhoneWk>	

MOBILE: <PtPhoneMob>	

E-Mail <PtEmail>	

MEDICARE NUMBER
<PtMCNo>	PENSION NUMBER
<PtPensionNo>	
DVA NUMBER
<PtDVANo>	HEALTH INSURANCE
<PtHealthIns>	

TRANSLATOR REQUIREMENTS	 <Translator Required>	LANGUAGE 	 <If yes, language required>	

PATIENT CONSENT	   <Patient Consent>	ABORIGINAL or TSI 	 <Aboriginal or TSI>	

CLINICAL INFORMATION
PAST MEDICAL HISTORY	
<SelectedPMH>
<Any other relevant history/diagnosis>	
ALLERGIES
<Reactions>	
CURRENT MEDICATIONS
<SelectedRx>	
INVESTIGATIONS
<Ix>	
SOCIAL HISTORY
<SocialHx>	

GP SIGNATURE		DATE	<TodaysDate>