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

FAX TO: 9382 4612
PHONE ENQUIRIES TO: 9382 4600	

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

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: <<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 (HbA1C, Biochemistry & FBC)
<<Summary:Investigation Results (Selected)>>	
SOCIAL HISTORY
<<Clinical Details:Social History>>	

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