Client Details	
Patient Name:
DOB:	Gender: M     F 	
Patient Address.	
Date of Referral:	Phone home:	Mobile:	
Healthcare/Pension Card? Y	N	Card Number:	Expiry Date:	
Medicare Card Number:	Expiry Date:	ATSI registered?	Y	N	
Referring GP Details	
GP Name:
Practice Name:
Practice Address:	If this service was not available, would you have referred patient to hospital outpatient clinic?
Y	N	
Service Required	
Type 2 Complex Diabetes

Type 1 Diabetes		Gestational Diabetes
(please note, this will be shared care with KEMH/FSH)
General Endocrinologist Service	
Please ensure appropriate documents are attached	

Referral Letter addressed to “Dear Specialist” outlining requirements, current issues
Patient requires allied health services – please attach a GPMP/TCA and EPC Diabetes Educator – GPMP/ TCA and allied health referral (EPC) required
Exercise Physiologist - GPMP/ TCA and allied health referral (EPC) required
Dietitian - GPMP/ TCA and allied health referral (EPC) required

360 Health + Community will, where appropriate, direct your patients to other programs and allied health professionals to assist the patient to make lifestyle changes.	

GP Referral to 360 Health + Community Coordinated Endocrinology and Diabetes Service

Please fax to 360 Health + Community on 08 9279 8221

This program is supported by Department of Health WA
Version 3 updated: 5.11.15