Lambeth Diabetes Intermediate Care Team Referral form (Version Sept 2015)
This form can be used to refer to all the services provided by the Lambeth Diabetes Intermediate Care Team.
This form is for routine referrals only. If you wish to refer a patient urgently please telephone the on-call
diabetes registrar at Guys and St Thomas’s (020 7188 7188) or King’s (020 3299 9000).
Guidance on where patients should be referred can be found in the “Lambeth Management and referral checklist
for people with established diabetes.” Patients with type 1 diabetes, diabetes in pregnancy and
preconception care should be referred to secondary care.
Date of referral
Patient information
Practice information
Name of patient
Name of referrer
Address
Practice address
Patient contact information:
Practice contact information:
Landline number:
Telephone:
Mobile number:
Fax:
Email:
Referrers email:
How would the patient prefer to be
contacted?
Does the patient require transport to get to
the clinic?
By post
Yes/No
By text message
By email
Other patient information:
Does the patient have a carer/advocate?
NHS number
Hospital number
Name of carer
Date of birth
M/F:
Carer contact details
Translator required?
Language/Ethnicity
What type of diabetes does the patient have?
Type 1
Type 2
Recent measurements and tests
(measured within the past month)
Date of
diagnosis
Date
Result
HbA1c (% or mmol/mol)
Creatinine
eGFR
Total cholesterol
ACR
Blood pressure
Body mass index
Current medications
1
6
2
7
3
8
4
9
5
10
Has the patient been intolerant to any
medication previously prescribed?
Please provide information here.
Does the patient have any allergies?
Past medical history
Diabetes complications

Service required
Community diabetes clinic at
Gracefield Gardens

Service required
DESMOND (for patients with type 2
diabetes diagnosed within the past 18
months)
DESMOND foundation (for patients
who have had type 2 diabetes for
more than 18 months)
Food and diabetes group at
Gracefield Gardens
Community diabetes clinic at
Springfield Health Centre
Community diabetes clinic at
Akerman
Community diabetes clinic at
Norwood Health and Leisure Centre
Reason for referral (please provide information below)
Please send the completed referral form:
By email: LAMCCG.diabetes@nhs.net
By post: Lambeth Diabetes Intermediate Care Team, Crown Dale Medical Centre, 61 Crown Dale,
London, SE19 3NY
Telephone: 020 8655 7842
For Office Use ONLY……………………………………………………………………………………………
Date/Time received:
Triage Date/Time:
Triage Outcome:
Triaged By:
Desmond
Food Group
Community Clinic Admin:
Appointment Date/Time:
Community Clinic
ISG
Exenatide
Other: …………………………………………………
Venue:
Springfield
Gracefield
Date appointment confirmation letter sent to patient:
1st Attendance Outcome:
Desmond Admin:
Date Opt in letter sent to patient:
Course Booked for:
Completed
Attended Session 1 only
Non Responder
Other:
Completion/DNA/No response letter sent to referrer:
Venue:
Attended Session 2 only
DNA’d
Akerman