PRIORITY ALLIED HEALTH SERVICE – REFERRAL FORM
Diabetes Education
Patient to be seen by Hunter Primary Care Credentialed Diabetes Educator at:
Aberdeen, Denman, Muswellbrook, & Scone

Referral Date:	  	

Referring GP:	   	
Provider No:	

GP Contact Details:	

Patient Name:	  	

Patient DOB:	  	
  Gender: 	

Patient Address:	  	

Patient Telephone(s):	

Medicare/DVA number:	   	

Consent:	
Has the patient consented to this referral?	  Yes 	   No	

Aboriginal and/or Torres Strait Islander:	
   No 	   Aboriginal	   Torres Strait Islander	   Unknown	

Living arrangements:	
   Lives Alone	   Family/Carer 	   Friend	  Unknown	
Reason for Referral: 
(please tick below) 	
Diabetes review 		Insulin commencement		
T1DM		Insulin pump		
T2DM		Insulin adjustment 		
GDM		Continuous Glucose Monitoring		
Unstable diabetes /acute problem		Commencement of Saxenda or similar 		
  GP signature:	

Please email this referral to concierge@hunterprimarycare.com.au or fax to 02 4925 2268

Enquiries to concierge@hunterprimarycare.com.au or Phone 4935 3063