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Refer a patient

Diabetes team - referral form

To find out how we use this information, our security and your rights visit our privacy page >

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The importance of sharing information with all professional staff involved in the patients care has been explained to the patient or carer


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Interpreter required: * required


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Type of diabetes: * required





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Reasons for referral: * required













HbA1c(mmol/mol)

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Blood pressure

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eGFR

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Height (m)

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Weight (kg)

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BMI (kg/m2)

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Waist circumference (cm)

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For referral to be accepted please attach or input relevant past medical history and current medications



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You will see a thank you page once the form has been submitted. If you do not see this page then you have overlooked to complete some of the required fields. Please check the form, complete the missing details and resubmit. Thank you.

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