Richmond Health Services
FAX completed forms to
604-244-5571
Diabetes Education Referral
PATIENT INFORMATION
Name: __________________________________________________________
Last Name
PHN #: ________________________________
First Name
Address: ________________________________________________________
Birthdate: ______________________________
(dd / mm / yy)
City _______________________________ Postal Code __________________
Contact Phone: ______________________ Other _______________________
 Yes
LANGUAGE Translator required
 Cantonese
 Mandarin
Age: ______________ Sex:
M
F
Family support
 Yes  No
 No
 Other:
GROUP EDUCATION CLASS: REASON for REFERRAL
 Pre-Diabetes Class
 Type 2 Diabetes Class
Pregnant clients
 Type 1
 Type 2
 GDM
 IGT
 EDC ___________________________________
INDIVIDUAL APPOINTMENT with Dietitian and/or Nurse Educator: REASON for REFERRAL
 Dietitian
Diabetes Type
For Type 1 Diabetes
Barriers to learning in a group/class
 Nurse Educator
 Prediabetes
 Newly Diagnosed
 Frail Elderly
 Both
 Gestational
 Pre-Existing
 Cognitive Impairment
 Type 2
 Follow-up Consultation
 Other __________________________
 Type 1
INSULIN START/CHANGE REQUESTS (INSULIN Rx REQUIRED)
 Insulin Ordered
Type _____________________ Dose _______________ Time _____________ Weight ______________
 Titration Ordered: Increase by______________ units at _______________ (time) every 2 night / day until ______________
(am / pm / hs)
Readings are consistently under ______________________________________________ (glycemic target)
 Oral Medication (type/time): _____________________________________________________________________________
CURRENT HEALTH INFORMATION (List or Attach)
List Other Medications: _______________________________________________________________________________________
Related Medical History / Consult Notes: _________________________________________________________________________
Lab Results: (FBS, RBS, A1C, Lipid Profile, OGTT, Serum Creatinine, Urine for ACR)
PHYSICIAN INFORMATION
Name: _______________________________________________
Signature/Number: ________________________________
Address: _____________________________________________
Phone: __________________________________________
City _____________________________ Postal Code _________
Fax: ____________________________________________
FOR OFFICE USE ONLY: Appointment booked: ___________________________________________
Day
Month
Year
Comments:
February 2010
106728720
See over for more information
-2-
Diabetes Education Centre Referral Form Instructions
DO NOT FAX THIS SIDE when referring patients to the centre. This information is for your use only.
PATIENT INFORMATION
 Affix Label, Print or Stamp
LANGUAGE


Clients preferring service in Cantonese or Mandarin can attend classes or individual appointments at the Garratt Wellness Centre site
All other clients receive services at the hospital site. An interpreter will be booked for clients requiring translation in other languages.
PREDIABETES GROUP EDUCATION


Fasting glucose 6.1- 6.9 and/or blood glucose at 2 hrs OGTT 7.8-11.0
One class with dietitian and nurse educator
TYPE 2 DIABETES GROUP EDUCATION



Fasting glucose 7 or more and or blood glucose at 2 hrs OGTT 11.1 or more
2 classes with dietitian and nurse educator
Richmond Hospital site Type 2 class participants (only) have an opportunity to see an internist
GESTATIONAL DIABETES GROUP EDUCATION


1 class with individual follow-up with dietitian and nurse educator
Clients receive service and support throughout their pregnancy
INDIVIDUAL APPOINTMENTS





Clients can consult with a dietitian, nurse educator or both.
Note that GDM clients attend class and receive individual appointments
Type 2 patients attend class followed by individual appointments if desired
Clients who find group participation difficult due to e.g., vision, hearing, frailty, cognitive or behavior impairment may prefer to have
individual appointments
Clients will be contacted to register for individual appointments.
INSULIN START/CHANGES



Details of insulin prescribed is required
Inpatients must have received discharge prescription before referral to the diabetes nurse educator
Please do not refer an inpatient without a discharge prescription for the insulin to be used at home
CURRENT HEALTH INFORMATION


List or attach relevant information
Client to bring medications / prescriptions to appointment
PHYSICIAN INFORMATION (REFERRING)


Physicians will be notified if client does not register for class or individual appointment
Recommendations for clients seen by an internist at the Richmond Hospital site will be forwarded to the family physician
DIABETES EDUCATION CENTRE – CONTACT INFORMATION


Richmond Hospital site:
604. 244. 5163 Monday –Thursday
Garratt Wellness Centre site:
604. 204. 2007
February 2010
106728720
Thursday – Friday (Saturday classes have no receptionist)