Referral to RDNS Injectable
Therapy Initiation Project
Referrer: Please complete this form and send it to RDNS by fax (1300 65 72 65) or post (Level 2, 1155 Toorak Road, HARTWELL VIC 3124).
Referrals from hospitals: Please give this form to your RDNS Liaison nurse if available (if you fax it, please send the original with client/family).
Referrers only: To re-order, email your address and contact details to purchasing@rdns.com.au
CLIENT DETAILS:
Name:
RDNS UR:
Patient
(Given name)
(Family name)
Address:
Phone:
Date of birth:
Gender:
Next of kin/contact:
Interpreter required:
(if known)
M
F
Phone:
 No
 Yes:
Language spoken at home:
Diabetes Type:
Date of Dx:
(Note: Ineligible for HIIT-D project if type
1 diabetes or gestational diabetes )
HbA1c Result (or attach):
Relevant past history:
Date
HbA1c date tested:
Condition
Or attach summary
Allergies:
Allergy/Adverse Reaction
Reaction
Severity
Pension/DVA number:
Client is aware of referral:
(if applicable)
 Yes
 No
GP details:
Phone:
Name:
Fax:
Address:
RDNS SERVICES/CARE REQUESTED:

(Tick as many as required)
Injectable therapy initiation for type 2 diabetes *
© RDNS Ltd
For review 9/2016
Version 5.2 DM study —July 2015
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Patient name: ___________________________
Please tick the injectable to commence:
STARTING INSULIN DOSE (Cross through those not applicable)
Insulin Type
Dose
Strength
Frequency
☐ Lantus
☐ _______________
Route
10 units
(100 units/ml)
☐ Daily
(timing agreed with client)
SC
10 units
(100 units/ml)
☐ Daily
☐ Before breakfast
SC
☐ Before dinner
(premix insulin)
REPORTABLE BG LEVELS FOR INSULIN OR EXENATIDE (Consult with CNC Diabetes or GP if outside range)
Fasting blood glucose target range (BGL): <6☐; Other (please specify)
(mmol/L)
Reportable BGLs: Hypoglycaemia < 4.5 (mmol/L) Hyperglycaemia >20 (mmol/L) Other (please specify)
INSULIN ADJUSTMENT PROTOCOL
Insulin dose adjustment:
 Fasting morning BG level checked daily, other monitoring as required.
 If average fasting BG is above target range, adjust the insulin dose by 2 units every 3-4 days
 If average fasting BG level is within target, no change in dose
 If BGL less than 4.5mmol/L reduce the insulin dose by 2 units
 RN to record the insulin dose administered by the client / carer in progress notes each visit
EXENATIDE (BYETTA) COMMENCING DOSE (Cross through if not applicable)
Name
Dose
Frequency
Route
Exenatide
5 mcg
BD (pre-meal)
SC (abdo or thigh)
Please reduce the dose of _________________________________ by half on commencement of Byetta

Patients on sulphonylureas have increased risk of hypoglycaemia. Consider temporary dose reduction by 50% initially.
Administer Exenatide within 60 minutes prior to the two main meals of the day. Ensure a minimum of 6hrs between these meals. Exenatide
should not be administered after a meal

Additional notes for commencing exenatide:
 Check blood glucose 4x daily for the initial 3 days of commencing Byetta
 GP review and increase to 10mcg twice daily in 1 month unless not tolerated or eGFR<30
 GP to titrate sulphonylureas according to glucose readings once stabilised
For insulin or exenatide, please communicate progress with GP:
Weekly 


Fortnightly 
Monthly ☐
Other (specify frequency):
I authorise commencement of Exenatide
I authorise the RDNS Registered Nurse liaising with the Diabetes CNC to commence
insulin and to instruct this client and/or carer on insulin dose adjustment as per the
above protocols.
Signature of Medical Officer:
Provider Number:
Print Name:
© RDNS Ltd
For review 9/2016
Date:
Version 5.2 DM study —July 2015
Page 2 of 2
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Patient name: _______________________
MEDICAL AUTHORITY – OTHER MEDICINES (or attach list):
Drug Name
Strength
Doctor’s name (print):A/Prof Ralph Audehm
RELEVANT INFORMATION:
Dosage
Signature:
Date:8/7/2015
* Please advise if there is any actual or potential risk to RDNS staff security.
Cognitive status:
Continence:
Mobility:
Client safety issues:
Carer:
At risk:
Access to home:
Other:
REFERRER if not GP:
8/7/2015
(Signature)
© RDNS
For review 12/2006
(Name-please print)
Version 5.2 DM study—July 2015
(Date)
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