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
Patients living outside of the catchment area of Liverpool Hospital are NOT eligible for review. 

Dear <<Addressee:Name>>
Patient Information	
Family name:<<Patient Demographics:Surname>>	Given Names: <<Patient Demographics:First Name>>	
Sex: <<Patient Demographics:Gender>>	Date of Birth: <<Patient Demographics:DOB>>	
Address:  <<Patient Demographics:Address Line 1>> <<Patient Demographics:City>> <<Patient Demographics:State>> <<Patient Demographics:Postcode>>	Aboriginal and Torres Strait Islander Status: <<Patient Demographics:ATSI>>	
Phone number: <<Patient Demographics:Phone (Mobile)>> /  <<Patient Demographics:Phone (Home)>>	Family/carer phone number: <<Family/carer phone number>>: 	
  Interpreter Required: <<Patient Demographics:Requires Interpreter>>               Language: <<Patient Demographics:Language Preferred>>	
Medicare Number: <<Patient Demographics:Medicare Number>>	Medicare Expiry date: <<Patient Demographics:Medicare Expiry Date>>	
SERVICE REQUIRED:
<<Services 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:	

<<Referral Reason>>	
   Please attach all relevant pathology including HbA1c and eGFR as well as most recent medication list

Referring Doctor	
Doctor's Name: <<Doctor:Name>>	Phone: <<Doctor:Phone>>	
Address: <<Doctor:Address Line 1>> <<Doctor:City>> <<Doctor:State>> <<Doctor:Postcode>>	Provider Number: <<Doctor:Provider Number>>	
Email: <<Doctor:E-mail>>	Fax: <<Doctor:Fax>>	
Signature:	Date: <<Miscellaneous:Date>>