Prince of Wales Hospital Diabetes Centre
Podiatry: High Level & Complex Diabetic Foot Care

FAX TO: 9382 4612
PHONE ENQUIRIES TO: 9382 4600	

REFERRAL DATE: <TodaysDate>

NOTE: The High Level Care Podiatry Service is only for patients who have diabetes. This service does not accept referrals for basic nail or foot care for people with or without diabetes. 
 
To: Dr Ann Poynten, Dr Barbara Depczinsky, Dr Kerry-Lee Milner, Ms Jayne McGreal

Patient has ONE of the following 

Current Foot ulcer	

Previous Foot Ulcer	

Previous Diabetes related amputation	

Neuroarthropathy “Charcot’s” Joint  	

Suspected Neuroarthropathy 	

OR
Patient has TWO of the following                                                    
	
Peripheral Neuropathy 	

Peripheral Vascular 	

Foot Problems such as callus, corn, toenail pathology, foot structure problems (please describe below)	

	Other services currently involved in patient’s care

Vascular Team	

Orthopaedic Team	

Infectious Disease team	

Hyperbaric Medicine	

Community Nursing	

Orthotic Department	

Post-Acute Care Services	

Transitional Aged Care	

Podiatrist	

Other:

	

Details FOR REFERRAL (Mandatory For ALL Referrals)
<Reason for referral>

	TYPE OF DIABETES:
<Specify type of Diabetes:>	
Patient’s Weight:	Patient’s HbA1c:	
Indefinite referral: Yes/No		
Please attach a full medical history and Medication List with this referral	
This referral extends to include review in the Multidisciplinary Diabetes Foot Clinic referral in POWH Ambulatory Care Unit if indicated : Yes / No	

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	
<PMHAll>
<Any other relevant history/diagnosis>	
ALLERGIES
<Allergies/Adverse Reactions>	
CURRENT MEDICATIONS
<CurrentRx>	
INVESTIGATIONS (HbA1C, Biochemistry & FBC)
<Ix>	
SOCIAL HISTORY
<SocialHx>	

GP SIGNATURE		DATE	<Date >