Fairfield Hospital Diabetes & Endocrinology Service Referral Form 
    Please consider nominating a diabetes specialist 

Dr Vincent Wong
Dr Manimegalai Manoharan	
Referrals accepted via fax only 02 9616 8026
Patients living outside the catchment area of Fairfled Hospital are to be referred to their local hospital diabetes service 	

PATIENT INFORMATION 	
Family name: <<Patient Demographics:Surname>>	Given names: <<Patient Demographics:First Name>>	
Sex: <<Patient Demographics:Gender>>	DOB: <<Patient Demographics:DOB>>	
Address: <<Patient Demographics:Full Address>><<Patient Demographics:Full Address Postal>>	Aboriginal/Torres Strait Islander Status: <<Aboriginal/Torres Strait Islander Status >>	
Phone number: <<Patient Demographics:Phone (Home)>>	Family/carer phone number: <<Patient Demographics:Next of Kin Phone>>	
Medicare number: <<Patient Demographics:Medicare Number>>	Medicare expiry date: <<Patient Demographics:Medicare Expiry Date>>	
Interpreter required: <<Patient Demographics:Requires Interpreter>>	Language: <<Patient Demographics:Language Spoken>>	

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 information and pathology including HbA1c, eGFR and most recent medication list	

REFERRING DOCTOR 	
Doctors name: <<Doctor:Name>>	Phone: <<Doctor:Phone>>	
Address: <<Doctor:Full Address>>	Provider number: <<Doctor:Provider Number>>	
Email: <<Doctor:E-mail>>	Fax: <<Doctor:Fax>>	

Signature: <<Your name>>	
Date: <<Miscellaneous:Date>>	

Fax the completed form to 
02 9616 8026	

 Please attach all relevant additional infromation including patholody including HbA1c, and most recent medication list 

Medication
<<Clinical Details:Medication List>>

Investigation reports
<<Clinical Details:History List>>