St George and Sutherland Hospitals 
Diabetes Education Centres 

FAX to: 9113 2690 
Diabetes Centre staff will contact patient to arrange an appointment
Phone enquiries to: 9113 3090	

REFERRAL DATE: <TodaysDate>

DIABETES EDUCATION CENTRE: <DIABETES EDUCATION CENTRE>

HEALTH PROFESSIONAL: <HEALTH PROFESSIONAL>

REASON FOR REFERRAL (Mandatory For ALL Referrals)
<Reason for referral>	TYPE OF DIABETES

<Type of Diabetes>

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

PATIENT INFORMATION
NAME: <PtFullName>
	GENDER :  <PtSex>
                    	
COUNTRY OF BIRTH: <Country 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 	 <Language Required>	

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

CLINICAL INFORMATION

PAST MEDICAL HISTORY	
<SelectedPMH>

ALLERGIES
<Reactions>	

CURRENT MEDICATIONS
<CurrentRx>

INVESTIGATIONS
<Ix>	

SOCIAL HISTORY
<FamilyHx>

SMOKING STATUS
<SmkStatus>	ALCOHOL USE
<AlcHx>	
EXERCISE  
<Exercise>	DIET 
<Diet>	

GP SIGNATURE		DATE