Hamilton Niagara Haldimand Brant - Diabetes Education Program - Referral Form
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2Hamilton Niagara Haldimand Brant - Diabetes Education Program - Referral Form
Serving Hamilton, Niagara, Haldimand, Norfolk, Burlington and Brant
Referring Health Service Provider (or stamp)
Referral
Date:
mm/dd/yyyy
Please check one:
Name: ______________________________________________________
Niagara Zone: Fax - 1-905-682-3622
Organization Name: ___________________________________________
Hamilton/Burlington Zone: Fax -1-905-521-6128
Phone #: ______________________ Billing #:________________________
Haldimand Norfolk Brant: Fax - 1-519-751-5862
Signature: ___________________________________________________
Direct Referral - See page 2
Patient Information
Name: ________________________________________________ Gender:____________
DOB:
________
Address: ________________________________________________________________________________________
City: ___________________________________ Postal Code: _________________ Health Card #: ________________________
Contact Number: __________________________ Alternate Contact: _________________________________________________
Preferred Language of Service: _____________________________________
Translation Required?
Yes
No
Primary Care Provider: ____________________________________
Client's Preferred Location: ___________________________________
Reason for Referral:
Insulin Start
New Diagnosis of Diabetes
Is this referral urgent?
YES
NO
Other:
Type of Diabetes:
Type 1 MDI
Type 1 Pump
Type 2
Pre-diabetes
At Risk
Paediatric
Gestational
Pregnant Type 1
Pregnant Type 2
Other
# Weeks
# Weeks
# wks pregnant
Relevant Medical History OR
Most Recent Clinic Note Attached
*For Gestational – attach 50gm/75gm OGTT
Labs:
Please attach most recent relevant lab results.
Medications:
Please attach most recent medication list.
New Insulin Order:
Initiation
Change:
*Please ask client to fill prescription and bring to appointment
Canadian Diabetes Association Insulin Prescription Form Attached
Order Set:
Completed below
or
Adjust insulin by 1-2 units or up to 20% prn to achieve
Insulin Type:
CDA glycemic target of ac 4-7mmol/L and pc 5-10mmol/L or
Dose and Time:
individual target of:
Adjust insulin by 1-2 units or up to 20% prn to achieve CDA
Insulin Type:
glycemic target of ac 4-7mmol/L and pc 5-10mmol/L or individual
Dose and Time:
target of:
Start:
Oral Anti-
Hyperglycemic
Discontinue:
Agents:
Continue:
Pg 1
For Internal Use Only - Date Received at Central Intake:_____________ Date Received at Destination DEP:________________
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