Adult Outpatient Diabetes Services
REFERRAL FORM
Fax to Diabetes Service Available in Cochrane Sub-Region of NE LHIN (see reverse for description of programs)
MICs Diabetes Program
Matheson/Iroquois Falls/Cochrane/Smooth Rock Falls
Iroquois Falls Family Health Team (Rostered clients only)
MISIWAY Diabetes Wellness Centre
Iroquois Falls
F: 705-258-2828
Taykwa Tagamou & Wahgoshig First Nations
F: 705-264-6422
Health Sciences North-Complex Diabetes Care Program (Physician or NP referral required)
REFERRED BY:
MD
NP/RN/RPN
Community Care Provider
Name of Health Care Provider ________________________________
Sudbury
F: 705-671-5634
Other Diabetes Service
Other _____
Phone #______________________________
Client Name: __________________________________________________
(Last)
F: 705-258-2657
DOB: ______________________
(First)
HC #: ____________________________________
Client Language Preference:
English
Gender:
French
Male
Female
Other__________________
Client Address: ___________________________________
Barriers to learning: ________________________
(include postal code)____________________________________________
__________________________________________________
Client Phone #: (H) __________________________________
(C or W) __________________________________
SERVICES REQUIRED:
Nurse Educator
Dietitian
Diet at discretion of dietitian
Other diet:_________________________
Insulin start/management - Please attach insulin prescription form
Consent for Certified Diabetes Educator to teach patient insulin dose adjustment by 1-2 units or 10-20% of daily dose
DIAGNOSIS or REASON FOR REFERRAL:
Type 1
Type 2
New Diagnosis
CURRENT DIABETES TREATMENT:
Pre-Diabetes (IGT/IGF)
GDM
Year of Dx: _________
Lifestyle
OTHER ______________________
Previous Diabetes Education
Oral/injectable antihyperglycemic
Yes
No
Insulin
MEDICATION LIST: **Please attach or fill in:
Please order and attach results
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HbA1c
Fasting BG
2 hr GTT
Lipid Profile
eGFR, Albumin/Creatinine ratio
Creatinine, Urea
B12
TSH, T4
COMORBIDITIES:
CVD
Dyslipidemia
Hypertension
Obesity
PVD
Foot Conditions
Renal disease
Retinopathy
Neuropathy
Mental Health Issues
Sexual dysfunction
Other:
REFERRING HEALTH CARE PROVIDER SIGNATURE:
Office Use Only
Appointment date:
Date received:
FOR PREGNANCY:
Gravida:
Para:
EDB:
Weeks pregnant:
OGT:
Date:
Date:
Date
triaged:
Individual
Initials:
Group
OTN
Description of Diabetes Services in Cochrane Sub-Region
Diabetes care and
management by
specialized team
Diabetes care and
management by
specialized team
Diabetes care and
management by
specialized team
Diabetes Care with
Complex Health
Requirements
MICS Diabetes
Program Head Office
241 Eighth St
Cochrane, ON
P0L 1C0
Tel: 702-272-7200 ext
1131
Fax: 705-258-2657
Iroquois Falls
Family Health Team
58 A Anson Drive
Iroquois Falls, ON
P0K 1E0
Tel: 705-258-2818
Fax: 705-258-2828
**Rostered patients
only**
MISIWAY
Diabetes Wellness
Centre
1500 Riverside Drive
West, Unit 58
Timmins, ON P4R 1A1
Tel: 705-264-3799
Fax: 705-264-6422
English/French
English
English
Health Sciences North
Complex Diabetes Care
Program
865 Regent St. S., 2nd
floor
Sudbury, ON P3E 3Y9
Tel: 705-671-6601
Fax: 705-671-5634
**Physician or NP
referrals only**
English/French
Prediabetes education
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Initial/basic diabetes education
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Self blood glucose monitoring
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Nutritional counseling re:
healthy eating
Management with oral
hypoglycemic
Lifestyle management
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Advanced diabetes education,
management and treatment
Intensive management
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Insulin start and management
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 nutrition only
High Risk Foot Care
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Complications screening and
management
Diabetes and comorbidity
education, management and
treatment
Consultation with an interprofessional care team including
endocrinologist, nephrologist,
psychologist, pharmacist,
ophthalmologist and chiropodist
Health care system
navigation/case management for
patients who have difficulty
accessing the health care system
(i.e. multiple co-morbidities,
mental health problems)
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**Attach Insulin Prescription Form
Specialized nutrition counselling
including carb counting,
specialized plan, etc.
Gestational Diabetes and
Pregnancy in Type 1 and 2
Please consider having
clients assessed by one
of the local Diabetes
Education Programs
prior to referring to
Health Sciences North
Complex Diabetes Care
Program
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