(Diabetes Education and Self Management for Ongoing and Newly Diagnosed)
Referral form Patient details Surname:............................................................. First name:..................................................................... Address:.................................................................................................................................................... ................................................................................................................................................................. ............................................................................Post Code:..................................................................... Telephone No:............................................................................................................................................ Date of Birth:............................................................................................................................................. Sex:...........................................................................................................................................................
Date of diagnosis .................................................................................................................................................................
Practice details GP Name:.................................................................................................................................................. PN Name:.................................................................................................................................................. Address:.................................................................................................................................................... ................................................................................................................................................................. ............................................................................Post Code:..................................................................... Telephone No:............................................................................................................................................
Date of completion of form ................................................................................................................................................................. PLEASE ATTACH BIOMEDICAL DATA FOR PATIENT TO THIS FORM IF AVAILABLE OR AS SOON AS POSSIBLE AFTER RESULTS HAVE BEEN RECEIVED (It is crucial these results are available prior to the patient commencing the DESMOND programme).
Return to: Gillian Longbottom, Diabetes Project Co-ordinator, NHS Kirklees, St Luke’s House, Blackmoorfoot Road, Crosland Moor, Huddersfield, HD4 5RH
3.10
Section 3 - rehabilitation and education programmes