Hounslow Diabetes Intermediate Care Service Referral Form
Routine and urgent telephone helpline:
Email contact for routine clinical queries:
07815716838
CLCHT.HounslowDiabetesICSService@nhs.net
Patient
Referrer
Name:
Name:
Practice e-code:
Practice Address:
Address:
Telephone:
DoB:
NHS Number:
Email:
Telephone:
Fax:
E-mail:
Assistance with Booking
Yes
No
Referred by:
GP
GMC no:
Interpreter Required
Transport Required
Yes
No
Language
Consent to share record
Yes
No
Ethnicity
Mental Health/ Learning Disability
Yes
No
Referral Date
Gender:
PN
Yes
Other
No
Referral Priority/ Patient Access
Routine
Urgent, please give reason
24hour foot care assessment, please give reason
Patient will attend clinic
Patient requires domiciliary care
Joint home visit with GP/ practice nurse
Patient to be seen in joint clinic (where arrangements are in place with locality)
Locality: HOH
Feltham
Chiswick/B&I
Great West
Reason for Referral
Referral To: Consultant
DSN
Podiatry
Patient Education: Holding Off (Pre Diabetes)
Dietician
Psychology
Type 2 X-pert/Conversation Maps
Type 1 DAPHNE
Poor control and on Maximum tolerated oral agents up to triple therapy
Recurrent Hypoglycaemic episodes
Poorly controlled hypertension or hyperlipidaemia
Other
Diagnosis and Relevant Medical Details
Please complete all
sections:
Year of Diagnosis
Type 1
Type 2
Type 2 + Insulin
If recently diagnosed please supply blood glucose results
Please send referrals to the REFERRAL FACILITATION SERVICE:
as an email attachment to Hounslow.RFS@nhs.net (This is a secure NHS email address).
For practice enquires please telephone: 05511 434910
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BP
Weight
Height
BMI
Smoking & Alcohol
ACR
HbA1c
Total Cholesterol
HDL
LDL
TG
DESP Date
U&E
Creatinine
EGFR
LFT
TFT
DESP Result
Additional Information e.g. Foot assessment risk:
History, Past Medical History, Medication, Allergies, Examination
Please state secondary care provider if referral requires secondary care input. If preference is not indicated provider
will be assigned by postcode.
West Middlesex
Ealing
Imperial College
Other (please Specify)
Chelsea & Westminster
Ashford & St Peters
Please note, incomplete referrals will be returned to the referrer.
Please send referrals to the REFERRAL FACILITATION SERVICE:
as an email attachment to Hounslow.RFS@nhs.net (This is a secure NHS email address).
For practice enquires please telephone: 05511 434910
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