Wiltshire Primary Care Trust .uk
[pic]
|Wiltshire Community |
|Diabetes Specialist Nurse Referral Form |
|Personal/Clinical Details |
|PLEASE CAN YOU COMPLETE ALL FIELDS |
|Patient Name: |Referred by: |
| |Name: |
|Address: |Title: |
| |Telephone: |
| | |
|Post Code: |GP: |
| |Surgery Address: |
|Date of Birth: | |
| |Post Code: |
|Telephone Number: | |
| |Telephone number: |
|NHS. No: | |
| |Consultant: |
|Date of Referral: |Other HCP involved – Contact Details: |
| | |
| |…………………………………………….. |
|Type of Diabetes: | |
| |If Inpatient – Ward and Contact Number: |
|Date of Diagnosis: | |
| |
|Other medical conditions: |Blood Glucose Meter Type: |
| |(Monitoring Mandatory) |
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| |(last 2 results of the following) |
|Diabetes Medication: (including doses of tablets and insulin) |HbAlc |
|Attach Repeat Prescription List if possible |Date |
| |HbAlc |
| |Date |
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| |Chol |
|Other Medication: |Date |
| |Chol |
| |Date |
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| |S Crea |
| |Date |
| |S Crea |
| |Date |
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| |eGFR |
| |Date |
| |eGFR |
| |Date |
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| |Weight |
| |Date |
| |Height |
| |Date |
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| |BMI |
| |Date |
| |B/P |
| |Date |
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| |Allergies: |
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|PLEASE CAN YOU ENSURE THAT YOU COMPLETE INFORMATION ON PAGE 2 |
Page 1
|Reason for Referral: (PLEASE COMPLETE) |
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|Other relevant information: (PLEASE COMPLETE) |
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Please send to:
West Wiltshire Diabetes Team
Trowbridge Community Hospital, Adcroft Street, Trowbridge BA14 8PH
If urgent, Telephone 01225 711443 Email: whc.diabetesreferrals@
North Wiltshire Diabetes Team
Chippenham Community Hospital, Rowden Hill Chippenham SN15 2AJ
If urgent, Telephone 01249 456483
South Wiltshire Diabetes Team
Salisbury Diabetes Education Centre, Salisbury Foundation Trust, Odstock Road, Salisbury, SP2 8BJ
If urgent, Telephone 01722 425176
Page 2
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