Prince of Wales Hospital Diabetes Centre

FAX TO: 9382 4612
PHONE ENQUIRIES TO: 9382 4600	

REFERRAL DATE: <<Miscellaneous:Date (short)>>

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: <<Doctor:Name>>	PROVIDER	<<Doctor:Provider Number>>	
ADDRESS:
<<Doctor:Full Address>>	PHONE
FAX
EMAIL	<<Doctor:Phone>>
<<Doctor:Fax>>
<<Doctor:E-mail>>	

PATIENT INFORMATION
NAME: <<Patient Demographics:Full Name>>	GENDER :  <<Patient Demographics:Sex>>  	
COUNTRY OF BIRTH: <<Patient Demographics:Country of Birth>>	DATE OF BIRTH: <<Patient Demographics:DOB>>	
ADDRESS
<<Patient Demographics:Full Address>>	HOME: <<Patient Demographics:Phone (Home)>>	

WORK: <<Patient Demographics:Phone (Work)>>	

MOBILE: <<Patient Demographics:Phone (Mobile)>>	

E-Mail <<Patient Demographics:E-mail>>	

MEDICARE NUMBER
<<Patient Demographics:Medicare Number>>	PENSION NUMBER
<<Patient Demographics:Pension Number>>	
DVA NUMBER
<<Patient Demographics:DVA Number>>	HEALTH INSURANCE
<<Patient Demographics:Health Insurance>>	

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

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

CLINICAL INFORMATION
PAST MEDICAL HISTORY	
<<Clinical Details:History List>>
<<Any other relevant history/diagnosis>>	
ALLERGIES
<<Clinical Details:Allergies/Adverse Reactions>>	
CURRENT MEDICATIONS
<<Clinical Details:Medication List>>	
INVESTIGATIONS
<<Summary:Investigation Results (Selected)>>	
SOCIAL HISTORY
<<Clinical Details:Social History>>	

GP SIGNATURE		DATE	<<Miscellaneous:Date (short)>>