LIVERPOOL HOSPITAL DIABETES 
SERVICE REFERRAL FORM
Dr Vincent Wong   	Dr Hamish Russell 	Dr Namson Lau	Dr Carmen Wong 	Dr Mani Manoharan	
Please consider nominating a diabetes specialist
REFERRALS ACCEPTED VIA FAX 02 8738 4539
OR EMAIL  SWSLHD-Liverpool-DiabetesandEndocrine-Referrals@health.nsw.gov.au
For patients living outside of the catchment area of Liverpool Hospital please refer to the local hospital diabetes service

Dear <AdrName>
Patient Information	
Family name:<PtSurname>	Given Names: <PtFirstName>	
Sex: <PtSex>	Date of Birth: <PtDoB>	
Address:  <PtStreet> <PtCity> <PtState> <PtPostcode>	Aboriginal and Torres Strait Islander Status: <Pt ATSI Status>	
Phone number: <PtPhoneMob> <PtPhoneH>	Family/carer phone number: <Family/carer phone number> 	
  Interpreter Required: <Interpreter Required>                   Language:  <PtLanguage Spoken>	
Medicare Number: <PtMCNo>/ <PtMCLine>	Medicare Expiry date: <PtMCExpiry>	
SERVICE REQUIRED:
  Group education o       Individual Allied Health/ Nursing review o      Medical review o

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:	

    <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>	
Address: <DrStreet> <DrCity> <DrState> <DrPostcode>	Provider Number: <DrProviderNo>	
Email: <DrEmail>	Fax: <DrFax>	

Signature:	Date: <TodaysDate>

Investigations:
<Ix>  

Medications:
<SelectedRx>