Diabetes Tasmania Clinical Services	

Clinical services are available statewide

Phone: 6215 9000 I Fax: 6215 9099 I HealthLink EDI: diabetas

Referral date: <TodaysDate>

Referrer details:
<DrName>  
<Practice>
<DrStreet> 
Provider number: <DrProviderNo>
Phone: <DrPhone>  
Fax: <DrFax> 	

Patient details:
Name: <PtTitle> <PtFirstName> <PtSurname>
Date of birth: <PtDoB> Gender: <PtSex>
Address: <PtStreet>
Phone: <PtPhoneH>
Mobile: <PtPhoneMob>		Ethnicity: <PtEthnicity>
ATSI: <PtATSI>
Interpreter required: <Interpreter required>
Language spoken: <PtLanguage Spoken>
Medicare number: <PtMCNo>
DVA number: <PtDVANo>
Patient consent: <Patient consent for referral to these services?>	

Diabetes diagnosis:  <Diabetes Diagnosis> 
Years diagnosed:     <Years diagnosed>    
Referral discussed:     <Referral discussed with patient>	

How we manage appointments: <How we manage appointments>

About our services: <About our diabetes service>	

Describe currrent needs or goals of care:
<Describe current needs or goals of care>	

Injectable medication commencement:  <Injectable commencement >
GLP1 type: <Commencing GLP1>   
Insulin Type: <Insulin commencement>   Dose: <Commencing dose>   Frequency: <Frequency>   
Insulin Type: <Insulin commencement 2> Dose: <Commencing dose 2>Frequency: <Frequency 2>   	

Allergies and intolerances:
<Reactions>

Current and past medical history:
<PMHAll>

Current medications:
<SelectedRx>

Smoking status: <SmkStatus>

Please attach relevant pathology: Eg. OGTT HbA1c Total Chol HDL LDL Triglycerides Vitamin D TFT  FBC Micro alb. 
<Ix>