Diabetes Referral and Triage Form
PRIMARY CARE DIABETES SERVICE
FOREST PRIMARY CARE CENTRE, 308a HERTFORD ROAD, EDMONTON, N9 7HD
020 8344 3192
ARE KETONES PRESENT IN URINE? YES  NO  If YES please take the following action:
If within office hours: Patient to be referred immediately to Fast Track Nurse Led Clinic at NMUH or CFH.
STEP 1: Please discuss case with DSN by phone at NMUH on 020 8887 4238 or at CFH on 020 8375 1967
STEP 2: Please FAX this form directly to the Diabetes Centre at NMUH on 020 8887 4235 or CFH on 0208 375 1967
If outside office hours: Patient to be referred immediately to Accident and Emergency
Fasting
Random
WHO Diagnosis criteria
2 consecutive venous samples either fasting or random are required to
diagnose diabetes.
≥ 7.0 mmol / l
≥ 11.0 mmol / l
If osmotic symptoms are present (polydipsia, polyuria) then only one
sample is required
PATIENT DETAILS
Name
Address
Patient Post code
Contact telephone
Date of Birth
Gender
NHS Number
GP Name and address
GP Postcode
Ethnicity
If Linkworker required – please state language
Male  Female 
Is transport required? Yes 
No 
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PLEASE DO NOT USE THIS FORM TO REFER PATIENTS FOR RETINOPATHY SCREENING
Date of
results
HbA1c
Sodium
%
DIABETES HISTORY AND CLINICAL DATA
T.Cholesterol
AST
Potassium
Triglycerides
TSH
Urea
HDL
T4
Creatinine
LDL
Blood Pressure:
Weight:
Height:
Waist Circumference:
Smoking status
Is the patient newly diagnosed diabetes
Yes  No 
Type of diabetes: Type 1  Type 2 
Has patient received EPCT “Living with diabetes” booklet and
Diabetes hand held record?
MI /Angina
Renal
Acute Neuropathy
Alk
Phos
T
Bilirubin
T
Protein
Albumin
eGFR
A:C
Ratio
/
Kgs
M
Cms
Smoker  Non Smoker  Ex Smoker 
Date of diagnosis:
Patient is aware of diagnosis: Yes  No 
Yes  No 
Pt Name ………………………………………
KNOWN COMPLICATIONS
CVA / TIA
PVD
Foot Ulceration / Injury
Retinopathy
ED
CURRENT MEDICATION
Please state dose and frequency
Oral Hypoglycaemic Agents
Insulin
Other diabetes treatment
(e.g. Exenatide, Sitagliptin)
Lipid Therapy
Anti-hypertensive Therapy
Other
REASON FOR REFERRAL
Date sent……………….
Date received
Signature…………………………….. Print name……………………………..
ACTION (For office use only)
Date Accepted
Date triaged
2
Referral redirected to GP ___________
Referral redirected to choose and book
Appointment priority (please tick)
Appointment made at following clinic:
Nurse Consultant clinic
Preconception clinic
Diabetes Specialist Nurse clinic
Neuro-Vascular assessment
Diabetes Education (Routine / DESMOND)
Podiatrist only
Dietitian only
Triaged by
Details put on RIO Yes
Gen. Diabetes 
Renal 
Other(please state)
Urgent (within 1 week)
Routine
 No 
INCOMPLETE REFERRALS WILL REQUIRE US TO CONTACT YOU BY PHONE FOR MISSING
INFORMATION, THIS COULD RESULT IN A DELAY IN PROCESSING YOUR REFERRAL
THROUGH THE SYSTEM
DATA PROTECTION CONFIDENTIALITY NOTE
This message is intended only for the use of the individual or entity to whom it is addressed and may contain information that is privileged,
confidential and exempt from disclosure under law.
If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this
communication is STRICTLY PROHIBITED. If you have received this communication in error, please notify immediately by telephone and destroy
the document. Thank you.
Version 19 updated March 2012
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