FAIRFIELD HOSPITAL DIABETES & ENDOCRINOLOGY SERVICE REFERRAL FORM
REFERRALS ACCEPTED VIA FAX ONLY 02 96168026
Patients living outside of the catchment area of Fairfield Hospital are NOT eligible for review. 
Please consider nominating a diabetes specialist

Endocrinologists
Dr Vincent Wong
Dr Manimegalai Manoharan

    

  Dear  <AdrName>,

Patient Information	
Family name: <PtSurname> 	Given Names: <PtFirstName>	
Sex: <PtSex>	Date of Birth: <PtDoB>	
Address: <PtStreet>, <PtCity>, <PtState>, <PtPostcode>	Aboriginal and/or Torres Strait Islander:  <Aboriginal and/or Torres Strait Islander>	
Phone Number: <PtPhoneH> / <PtPhoneMob>	Family/Carer Phone Number: <NOKContact> / <NOKContact2>	
  Interpreter Required: <Interpreter Required:>     Language: <Language spoken>	
Medicare Number: <PtMCNo> / <PtMCLine>	Medicare Expiry date: <PtMCExpiry>	
SERVICE REQUIRED: 
<What Services are required?>  
Any patient with Type 2 diabetes or their carer can be referred for Group education	
REFERRAL CRITERIA
The GP can refer a patient to a Diabetes Specialist Service if the patient meets at least one of the following criteria:

	
<Relevant Referral Criteria (select ALL that apply)>
 	
   Please attach all relevant pathology including HbA1c and eGFR as well as most recent medication list

  Referring Doctor	
Doctor's Name: <DrName>	Phone: <DrPhone>	
Practice address:   <DrStreet>, <DrCity> <DrState> <DrPostcode>	Provider Number: <DrProviderNo>	
Email: <DrEmail>	Fax: <DrFax>	
Signature:                                                                                             Date: <TodaysDate>