<Selection Referral Region>

	
Referral 			

Referral Date: <TodaysDate>

Diabetes Tasmania Clinical Services
64 Cameron St Launceston, Tasmania  7250
88 Bathurst St Hobart,  Tasmania  7000
Phone: 03 6215 9000 / 1300 136 588
Fax:     03 6215 9099
Email:  mail@diabetestas.org.au	

Referring General Practitioner:
<DrName>  Provider No.: <DrProviderNo>
<DrAddress>  
Phone:  <DrPhone>   Fax: <DrFax>   Email: <DrEmail>	

Patient Details:
Name: <PtFirstName> <PtSurname> 
Date of Birth: <PtDoB>  Gender: <PtSex>
Marital Status: <PtMaritalSt>
Address: <PtAddress>
Phone:  <PtPhoneH>
Work:    <PtPhoneWk>
Mobile:  <PtPhoneMob>		
Ethnicity: <PtEthnicity>
Nationality: 
Interpreter Required: 
Pension Card Number: <PtPensionNo>
Medicare Number: <PtMCNo> / <PtMCLine>
DVA Number: <PtDVANo>
Patient Consent:
Has this patient provided consent for this referral? <Patient consent for referral?>	

Patient Assessment 

Reason/s for referral:
Launceston only - for Type 2 complex conditions requiring one-on-one appointments please attach the following:
•	General Practitioner Management Plan (GPMP)
•	Team Care Arrangements (TCA)
•	Allied Health Professional Individual referral form
Diabetes: (please highlight and 'x' reason for referral)		
o Type 2 new diagnosis suitable for DESMOND	o Newly diagnosed IGT	
o Type 2 new diagnosis unsuitable for DESMOND	o Type 1 requiring further education	
o Coach Program	o Type 2 requiring further education	
o Shop Well Eat Well 	o Injectable medication commencement	

Dietetics: (please highlight and 'x' reason for referral)
Exclusions - paediatric referrals, allergy and eating disorders		
o Type 1 diabetes 	o PCOS 	
o Type 2 diabetes	o Coeliac disease 	
o Overweight and obesity including Lapband and other           weight reduction surgery	o General healthy eating including bone health and                 vegan healthy eating 	
o Cardiovascular disease 	o IBS/FODMAP	
o Pre diabetes	o Malnutrition	
o Renal disease stage 1 and 2 	o Shop Well Eat Well	

Additional information/comments: 

	

Allergies and Intolerances:
<Reactions>

Current and Past Medical History:
<PMHAll>

Current Medications:
<SelectedRx>

Please attach relevant pathology: 
such as OGTT, HbA1c, Total Chol, HDL, LDL, Triglycerides, Vitamin D,TFT, FBC, Micro ALB. etc.
<Ix>

Signature: 
Date: <TodaysDate>