logo
What's New?

SELF REFER TODAY!

 

Why Self Refer For Diabetes Education?

Diabetes educators are licensed health care professionals—Registered Nurses and Registered Dietitians among others—who specialize in helping people with diabetes understand how to best manage their diabetes. The counseling and support that diabetes educators provide is known as diabetes education. Many of the healthcare professionals who provide these services also carry the designation Certified Diabetes Educator (CDE). Diabetes educators have a unique skill set and serve as essential support for patients and providers.

Individuals can initiate a referral for Diabetes Education. Please fill out the form below & submit it to the Mississauga Halton Central Intake Program for processing.

The Diabetes Education Program will contact you directly to schedule an appointment once they receive your referral.

Diabetes Self Referral Form

Name: 
Street: 
Unit/Apt.:
City: 
Province: 
Postal Code: 
Phone:   ext.
 
Sex: 
Healthcard Number:
Family Physician: 
I give the Mississauga Halton Central Intake Program permission to contact my family physician to obtain medical information to complete this referral.: 
Are you currently being followed by an Endocrinologist?:
If yes, please specify::
Do you Have:


When were you diagnosed with Diabetes:


Are you currently taking any Diabetes Medications?:


Best time to contact:


Have you attended a Diabetes Education Program in the Past: 
May we leave a Message: 
What is your Preferred Language:
Other, Please Specify:
Please select the preferral location where you would like to attend a Diabetes Education Program: 
If Other, Please Specify :
Is there anything else you would like us to know?: