Bankstown-Lidcombe Hospital Diabetes Referral Form 
Please consider nominating a diabetes specialist 

Dr Marwan Obaid titioner 
Dr Tang Wong  
Dr Sarah Abdo
Dr Eddy Tabet 
Dr Angela Lee	
Dr Ahmed Hussein 
Dr Sarah Chalak
Dr Mikey Xie
Nurse Practitioner 	
REFERRALS ACCEPTED VIA FAX ONLY 9722 8366
For patients living outside of the catchment area of Bankstown-Lidcombe Hospital,
please refer to the local hospital diabetes service

Dear <AdrDetails>
PATIENT INFORMATION 	
Family name: <PtSurname>	Given names: <PtFirstName>	
Sex: <PtSex>	DOB: <PtDoB>	
Address:<PtStreet><PtCity><PtState><PtPostcode>	Aboriginal/Torres Strait Islander Status: <Aboriginal/Torres Strait Islander Status>	
Phone number: <PtPhoneMob>	Family/carer phone number: <NOKContact>	
Medicare number: <PtMCNo>	Medicare expiry date: <PtMCExpiry>	
Interpreter required: <Interpreter required>	Language: <Language spoken at home>	

SERVICE REQUIRED
Any patient with Type 2 Diabetes or their carer can be referrded for group education 	
Select service type: <Service required>	

REFERRAL CRITERIA 
The GP can refer a patient to a Diabetes Specialist Service if the patient meets at least one of the following criteria: 	
Select from referral criteria (atleast one) :  <Referral criteria>	
Please attach all relevant additional infromation including patholody including HbA1c, and most recent medication list
REFERRING DOCTOR 	
Doctors name: <RefName>	Phone: <RefPhone>	
Address:<RefAddress>	Provider number: <RefProvNo>	
Email:<RefEmail>	Fax: <RefFax>	

Signature: <Your name>	
Date: <TodaysDate>