BANKSTOWN-LIDCOMBE HOSPITAL 
DIABETES SERVICE REFERRAL FORM

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 <<Addressee:Name>>

Patient Information	
Family name:<<Patient Demographics:Surname>>	Given Names: <<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>>	
Sex: <<Patient Demographics:Sex at Birth>>	Date of Birth: <<Patient Demographics:DOB>>	
Address:  <<Patient Demographics:Full Address>>	Aboriginal and Torres Strait Islander Status:  <<Patient Demographics:ATSI>>	
Interpreter Required: <<Is Interpreter Required?>> (Please Circle) Language: <<Patient Demographics:Language Spoken>>	
Medicare Number: <<Patient Demographics:Medicare Number>>	Medicare Expiry date: <<Patient Demographics:Medicare Expiry Date>>	

REFERRAL CRITERIA
The GP can refer a patient to a Diabetes Specialist Service if the patient meets at least one of the following criteria:	

Endocrinologists/Nurse Practitioner
Dr Tang Wong                   
Dr Angela Lee
Dr Marwan Obaid            
Dr Sarah Chalak
Dr Sarah Abdo
Dr Eddy Tabet, 
Dr Ahmed Hussein, 
Dr Mikey Xie
Nurse Practitioner Clinic

<<Reason for Referral>>
	
      Please attach all relevant information including pathology including HbA1c and eGFR, most recent medication list

Referring Doctor	
Doctor's Name: <<Doctor:Name>>	Phone: <<Doctor:Phone>>	
Address: <<Doctor:Full Address>>	Provider Number: <<Doctor:Provider Number>>	
Email:  <<Doctor:E-mail>>	Fax: <<Doctor:Fax>>	

Signature:	Date: <<Miscellaneous:Date (short)>>