Diabetes Desmond Referral Form
Please email completed form to: [email protected]
Contact Centre, Kirk House, 97-109 High Street, Yiewsley, Middlesex UB7 7HJ. Tel 01895 486 127
Patient Details:
Name:
Address:
Post code:
Does the patient have a disability?
Yes No
Don’t Know
If yes, please provide details of the disability and are
any adjustments required?
GP Details:
Surgery Name and Address:
Post code:
Referrers Details (if different from GP):
Name:
Address:
Date of Referral:
NHS No:
D.O.B:
Gender:
Tel no (home):
Tel no (mobile):
Ethnicity:
<< Select >>
Is an interpreter required? Yes
If yes, which language?
No
GP’s name:
Tel no:
Fax no:
Role:
Tel No:
Fax No:
This section must be completed to ensure patient meets the criteria for DESMOND.
Date of diagnosis:
Latest Test Results (need two positive tests unless symptomatic and glucose >11.1):
Fasting Glucose >7: Test 1 Results:
Test 2 Results:
or OGTT (if done) Fasting >7:
2 hours >11:
or HbA1c >48:
Test 2 Results:
Test 1 Results:
Total Cholesterol:
HDL:
LDL:
BP:
BMI:
Or waist circumference:
Is the patient symptomatic?
--------------------------------------------------------------------------------------------------------------I can confirm that I have had DESMOND explained to me and I would like to attend.
Signed by Patient:
Signed by Referrer:
h t t p :/ / w w w . c nw l . n h s . u k
Date:
Version: Desmond 11/4/16
h t t p :/ / w w w . h i l l i n g d o n c o m m u n i t yh e a l t h . o r g . u k /
Version: Desmond 11/04/16