Incomplete referral form may result in processing delays and impact on the client’s care coordination
Please sign and submit the completed form to info@blackswanhealth.com.au or fax to 9201 0033
Please refer to the www.blackswanhealth.com.au for eligibility and exclusion criteria

Date of Referral: <TodaysDate>
1. CLIENT DETAILS
Title: <PtTitle>
Last Name: <PtSurname>
DOB: <PtDoB>
Address: <PtStreet>
Suburb: <PtCity>   Postcode: <PtPostcode>
Mobile: <PtPhoneMob>  Home: <PtPhoneH>
Emergency/Next of Kin name:
<NOKName>
Emergency/Next of Kin phone: <NOKContact>
Is the client of Aboriginal and/or Torres Strait Islander descent? <Is client Aboriginal and/pr Torres Strait Islander Descent?>	

Gender: <PtSex>
First Name(s): <PtFirstName>
Access Issues: <Access Issues>

Email: <PtEmail>	
2. REFERRER DETAILS
GP, Specialist or Other: <Is referrer a GP, specialist or other?>
Other: <Other, please specify:>
Referrer Name: <Referrer Name (GP skip):>
Position: <Referrer position (GP skip):>
Address: <Referrer Address (GP skip):>
Suburb: <Referrer Suburb (GP skip)>  Postcode: <Referrer Postcode (GP skip)>	
Phone: <Referrer Phone (GP skip)>  Fax: <Referrer Fax (GP skip)>
Email: <Referrer Email (GP skip):>	
3. GP DETAILS
GP's name: <DrName>
GP's practice: <Practice>
Address: <DrStreet>
Suburb: <DrCity>  Postcode: <DrPostcode>
Phone: <DrPhone>  Fax: <DrFax>
Email: <DrEmail>	GP Stamp:
	
4. REFERRAL INFORMATION
Which type of Diabetes does your client have:
<Which type of Diabetes does your client have:>
Date of diagnosis: <Date of Diagnosis:>
Is the client registered with NDSS? <Is the client registered with NDSS?>
Is the client suitable for a group education session? <Is the client suitable for  Group Education session?>
Current treatment:
<Current Treatment>
Other:<Other, please specify:>	

Current Medication (or attach):
<CurrentRx>
Other relevant medical condition(s):
<Other relevant medical condition(s):>
Other: <Other, please specify:>

Date of Last Pathology Testing (within 12 months): <Date of last Pathology Test (attach report or enter details)>
HbA1c		<HbA1c (mmol/mol)>  mmol/mol	
OGTT (newly diagnosed):  Fasting: <OGTT - Fasting (mmol/L)> mmol/L    one hour: <OGTT - one hour (mmol/L)> mmol/L    two hour: <OGTT - two hour (mmol/L)> mmol/L
Urinary Microalbumin	<Urinary Microalbumin (mg/L)>mg/L
BPSFIELD|C|10|||ACR		<ACR (mg/mmol)> mg/mmol
eGFR   		<eGFR>
Blood Pressure: 	<Blood Pressure>
Serum Creatinine   	<Serum Creatinine (micromol/L)> micromol/L	
Other:		<Other:>
Full Lipid Profile	
Cholesterol:  <Cholesterol (mmol/L)> mmol/L		TG:  <TG (mmol/L)> mmol/L
HDL:   <HDL (mmol/L)> mmol/L			LDL:   <LDL (mmol/L)> mmol/L

4. CONSENT TO REFERRAL
Please tick the appropriate boxes below. Black Swan Health is only able to accept referrals where the client / guardian has consented to the referral, either verbally or in writing.

[   ]  I consent to be referred to Black Swan Health

Client / guardian signature:  _____________________________    Date: __ / ___ / _____

Print Name:   _____________________________  

[   ]  I confirm my client has been assessed and meets the eligibility criteria for a referral to Black Swan Health 
[   ]  I have obtained verbal consent from the client / legal guardian to refer and provide their personal health information to Black Swan Health for further assessment

Referrer’s signature:   _________________________________      Date: __ / ___ / _____

Print Name:   _____________________________
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OFFICE USE ONLY – leave blank
Unique client number (Black Swan Health to generate): _________________________________