To make an appointment and send referrals to:
Make an appointment and send referrals to: 
mailto:swslhd-camdenoutpatients@health.nsw.gov.au
Fax: (02) 4634 4045 
Phone: (02) 4634 4028
Email: Renuka.Singh3@health.nsw.gov.au
			                                 
Wollondilly Diabetes Program Referral Form
This program is for people living with Type 2 Diabetes residing in the Wollondilly LGA
Dr Chau Tran - Endocrinologist 
DEAR DR <AdrName>
Date: <TodaysDate>

I would like to refer the patient with Type 2 Diabetes for:
           
     q Endocrinologist Consultation 
     q Diabetes Educator Individual Education
     q Diabetes Educator Group Education    
           
PATIENT NAME:	 <PtFullName>	
ADDRESS:	<PtStreet>,  <PtCity>, <PtState>, <PtPostcode>	
DATE OF BIRTH:	<PtDoB>		
PHONE NUMBER:	Home: <PtPhoneH> Mobile: <PtPhoneMob>	
MEDICARE 	<PtMCNo>	

AGE:<PtAge> 	 DURATION OF TYPE 2 DIABETES:<Duration of Type 2 diabetes years> year/s 	

The most recent HbA1c was <HbA1c level> on <HbA1c date>		

REASON FOR REFERRAL:  <Reason for referral>

Thank you for your advice and help in the continuing management of this patient.

Yours sincerely,

Referring Doctor: <DrFirstName>  <DrSurname>  Provider Number: <DrProviderNo>

Address: <DrStreet>,  <DrCity>, <DrState>, <DrPostcode>    Telephone: <DrPhone>

Signature: …………………………………………                                               Date: <TodaysDate>

 

PLEASE ATTACH

Clinical History:

<SelectedRx>

Current Medication List:

<PastRx>

Investigations:

<Ix>
<Urinalysis>