Adult Diabetes Tier 3 and Tier 4 Referral Form
This form is currently only in use for non Roehampton patients: refer to QMH as usual.
URGENT
For urgent referrals please call the on call medical team via switchboard
0208 672 1255 then fax form.
For routine referrals please complete this form in full and FAX to CBS on
0208 725 4582; (T) 0208 725 0007
ROUTINE
PATIENT’S DETAILS
Title:
M
F
Forename(s):
Surname(s):
NHS Number:
D.O.B:
Address (incl. postcode):
Daytime contact number:
Alternative contact number:
Is transport required?
YES
NO
ETHNICITY:
Interpreter?
YES
NO
LANGUAGE:
GP Details
Date of referral:
Referrer details if not GP
(GP surgery address is mandatory)
Date of referral:
Name of referrer:
GP Name:
Surgery address (mandatory):
Job title:
Location:
Contact number:
Fax number:
NHS.net email address:
Contact number:
Fax number:
Email address (safe to send patient information):
HISTORY AND INVESTIGATIONS
All fields must be completed.
Please attach patient summary and current medication or include details of PMH and medication in this section
Date of diagnosis of diabetes:
Type of diabetes (if known): Type 1 / Type 2 / other
History
Measurements
Height (cm)
Weight (kg)
BMI (kg/m2)
Blood Pressure (mm/Hg)
Urine Protein
Urine Ketones
HbA1c (mmol/mol)
Serum creatinine (umoI/I)
eGFR (ml/min)
Total cholesterol (mmoI/L)
LDL cholesterol (mmol/L)
HDL cholesterol (mmol/L)
Triglycerides (mmol/L)
Urine albumin/creatinine
Date
Results
Adult Diabetes Tier 3 and Tier 4 Referral Form
TIER 4 Please choose all that apply:
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Type 1 diabetes
Hypoglycemic unawareness
Osmotic symptoms, weight loss and ketonuria (Same day referral)
eGFR persistently <45
Malignant Hypertension (BPU or A+E)
Treated TC/LDL and/or TG>4/>2/>2 with FH of premature (<55) CVD
Considering or already on insulin pump
Starting on insulin or changing insulin regime when not practical in a
community setting
Acute visual loss (emergency eye clinic)
Disabling autonomic and peripheral neuropathic symptoms
Pregnancy (initiate referral on first contact)
Worsening claudication, consider vascular referral
Acute foot ischaemia or progressive ulceration (Emergency Podiatry
Referral)
Diabetes complicating other endocrine disease
Charcot’s (Emergency Podiatry Referral)
Severe erectile dysfunction continuing after first and second line
treatment
TIER 4
Thomas Addison
Unit, St Georges
Hospital Referral
YES
EMERGENCY diabetes podiatry referral
Call the podiatry department on 0208 725 2753 or fax a written referral to 0208
725 0240
TIER 3 Please choose all that apply:
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Acute and persistent symptoms of hyper/hypoglycemia
Progressive micro or macrovascular complications despite max therapy
including retinopathy
HbA1c > 10% despite max therapy and good compliance
Falling eGFR<60 despite max therapy
Unable to achieve BP target
TC/LDL and/or TG>4/>2/>2 despite max therapy
Starting on insulin or changing insulin regime when not practical in a
practice setting (Type 2 only)
ACR>70 or ACR>30 with microscopic hematuria after UTI excluded
Autonomic neuropathies
Planning pregnancy
Stable claudication (Community Podiatry Referral)
Stable foot lesion (Community Podiatry Referral)
Persistent abnormal LFTs>3 x upper limit after primary care medication
and lifestyle review and appropriate first line investigations
TIER 3
St John’s
Therapy Centre
Tier 3 Clinic
Referral
YES
Newly diagnosed Type 2 diabetes suitable for group education
DO NOT USE THIS FORM
YES
Download the DESMOND referral form.
For Office Use Only:
Appointment in Tier 3
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Consultant
DSN
Dietitian
Duration (circle):
New 20min/ FU 20min
New 30 min/ FU 30 min
New 45 min/ FU 45 min
Location:
Download the DESMOND
referral form
Triaged by:
Name:
Signed:
Date:
Adult Diabetes Tier 3 and Tier 4 Referral Form