Diabetes WA Referral Form
IMPORTANT NOTICE: The information contained in this document is confidential. If you receive this message in error, please notify us immediately and return the original message to Diabetes WA.
MY HEALTH RECORD: The Diabetes WA Clinic accesses My Health Record prior to and during appointments. If the client does not consent, please contact us at least 1 business day before the appointment.
MEDICARE REBATE (METRO ONLY): If patient is eligible for Medicare Rebates under GPCCMP, please attach.

URGENT referral: <Urgent?>	(Urgent referrals will attempt to be seen within 7 days)	
Client Details	
Title: <PtTitle>	Surname: <PtSurname>	Given names: <PtFirstName> <PtMidName>	
Address: <PtStreet>, <PtCity>, <PtState>	Postcode: <PtPostcode>	
DOB: <PtDoB>	Gender: <GenderIdentity> Birth Sex: <PtSex>	Ethnicity: <PtEthnicity>	
Telephone: <PtPhoneH>	Mob: <PtPhoneMob>	Email: <PtEmail>	
Medicare Number: <PtMCNo>	Reference No: <PtMCLine>	Expiry Date: <PtMCExpiry>	
Interpreter Required:	<PtInterpreter>	Language: <PtPrefLang>	
Referred By: 	Date Referral Sent: <TodaysDate>	
Title:	Surname: <UsrSurname>	Given Names: <UsrFirstName>	
Agency Name: <Practice>	Address: <UsrAddress>	Postcode:	
Telephone: <UsrPhone>	Email: <PracEmail>	Facsimile: <UsrFax>	
Future correspondence to be sent to:	
Name: <Future Correspondence To (if not usual GP)>	Email: <Future Correspondence Email>	Fax: <Future Correspondence Fax>	
Diabetes Type <Diabetes Type>	
NDSS Registration:	<NDSS Registration>	Date of Diagnosis: <Date of Diagnosis>	Urgent Referral: <Urgent?>	
Reason for Referral: <Reason for Referral>
	
Medications Profile Attached?  (If yes, list with dosage, frequency & route)	
<Patient-Medications-Attached-(else-supply)>	
Referred by Diabetes Connect consult:	<Referred by Diabetes Connect?>	
Pathology: Copies Attached: <Pathology Attached?> Else complete below.	

Medical History	
<Medical-History>

Allergies / Reactions	
<Reactions>
For more information, please contact:
Healthlink: DWATEL3H | Telephone referrals: 1300 001 880 | Fax referrals: (08) 9221 1183
| Country WA Email:telehealth@diabeteswa.com.au | Perth Metro Email: clinic@diabeteswa.com.au | Level 3/322 Hay Street Subiaco, WA 6008

The Diabetes Telehealth Services is delivered by Diabetes WA in partnership with 
WA Country Health Services.

Insulin Therapy Titration Form: 

Insulin Requiring - Does the client use Insulin? <Does this client require insulin?>	
Insulin Therapy Order (List Insulin type and starting dosage below)	
Insulin Type/s	Dose & Time	
<Long-Acting-Insulin-Type> 	<Long-Acting-Dose-and-Time>	
<Short-Acting-Insulin-Type>	<Short-Acting-Dose-and-Time>	
<Mixed-Insulin>	<Mixed-Insulin-Dose-and-Time>	
As this Patient’s Medical Officer - <Authorise-Diabetes-WA-CDE-to-Titrate-Clients-Insulin>	
By completing this form, I authorise  a credentialled diabetes educator at Diabetes WA to adjust Insulin doses via in-person, video conference and/or telephone consultations according to the adjustments and blood glucose targets listed below. Exceptions: Ryzodeg - 1-2 units weekly. Toujeo - 1 unit daily or 10% of dose.	
Target Glucose Range  / Size of Incremental Adjustments	
Type 1 & 2 Diabetes 
Fasting: 
4.0 to 6.0 mmol/L 
 
2 hrs Post Prandial 
5.0 to 10.0 mmol/L 
(rise of < 2-3 from pre-prandial).	Higher Range Clinically Appropriate
Target range: 
6.0 to 15.0 mmol/L

As clinically appropriate.
Adjusted based on individual needs or symptoms and risk of hypoglycaemia.	Pre-Pregnancy (ADIPS)
HbA1C 6.5% or less
Time in Range if applicable (3.5-7.8mmol/L): >70%
Gestational Diabetes (ADIPS)
Fasting:  4.0 - 5.2mmol/L  
2 hrs Post Prandial  4.0 - 6.7mmol/L 
Time in Range if applicable (3.5-7.8mmol/L): >90%
Type 2 in Pregnancy (ADIPS)
Fasting:  4.0 - 5.3mmol/L  
2 hrs Post Prandial  4.0 - 6.7mmol/L
Time in Range if applicable (3.5-7.8mmol/L): >80%	
Changes Required to Oral / Injectable Therapy:	
  <Changes-to-Glucose-Lowering-Agents>	
Medical Officer	
Title: 	Given Name/s: <UsrFirstName>	Surname: <UsrSurname>	
Practice Name: <LocationName>	
Address: <LocationAddress>	
Phone: <LocationPhone>	Fax: <LocationFax>	Email: <LocationEmail>	
•	This insulin therapy order is valid from the below date.
•	The order becomes invalid if there is a change in the patient’s medical officer, a change in insulin management, or at the request of the medical officer.
•	Diabetes WA is not a 24-hour service and therefore cannot provide urgent medical assistance to patients.
Signature:                                                                                          Date: <TodaysDate>	
Please return to:
Healthlink: DWATEL3H | Fax: (08) 9221 1183
Country WA Email:telehealth@diabeteswa.com.au | Perth Metro Email: clinic@diabeteswa.com.au 

Endocrinology Registrars Available

To discuss the diabetes medical management of your patient or you have an urgent matter, contact an endocrinology registrar 24 hours, 7 days a week at the following tertiary hospitals:

Fiona Stanley Hospital	–	6152 2222	
Royal Perth Hospital	–	6477 5213	
Sir Charles Gardiner Hospital	–	6457 3333	

Diabetes Connect
Call Diabetes WA Consultant Endocrinologist, or to book a Multidisciplinary Case Conference -  08 9436 6270
	https://www.diabeteswa.com.au/diabetes-connect/
Links for Clinical Support or Useful Information
Health Pathways
	https://www.communityhealthpathways.org/
RACGP General Practice Management of Type 2 Diabetes
	https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/management-of-type-2-diabetes/introduction
Appendix G. Types of Insulin Available
	https://www.racgp.org.au/FSDEDEV/media/documents/Clinical%20Resources/Guidelines/Diabetes/Appendix-G.pdf
Appendix H. Examples for Insulin Initiation and Titration
	https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/management-of-type-2-diabetes/appendices/appendix-2-guide-to-insulin-initiation-and-titrati
NDSS Health Professional Portal to Register and Change in Medication
	https://hp-portal.ndss.com.au/SignIn
Other factors you may wish to consider prior to initiation of insulin:
•	Patient competency – consider vision or hearing impairment, poor dexterity, cognitive impairment.
•	Preferably commence insulin at the beginning of the week to ensure the patient can access health professional support as required. Once commenced on insulin, encourage regular review.
•	Encourage patients to include a support person in education in case of emergency.
•	Develop with your patient a Sick Day Plan including hypoglycaemia treatment.