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DIABETES SERVICES REFERRAL
HOW TO REFER

 

Mississauga Halton - Adult Referrals

Electronic Referral
Register today to start submitting & tracking your referrals online

Faxed Referrals
• Download the common referral form or email the Central Intake Program to request an electronic copy
• When referring patients; please complete all sections of the referral form in order for the patient to be routed appropriately and   in a timely manner
• Submit only completed packages to Fax: 1-855-338-0442

Diabetes Education ReferralRequired Information

Please note that if any of the following items below are missing from the referral the Central Intake Program will be unable to process the referral & it will be sent back to the requesting practitioner for completion.
  • Patient Information
    Name, DOB, Address, Phone Number, Health card Number
  • Diabetes Diagnosis
    Requester has clearly indicated the diagnosis of diabetes
    ex: Type 1, Type 2, Pre-diabetes, Gestational Diabetes or Steroid-Induced
  • Assessment Data
    A1C, eGFR are required for the last 6 months
  • Current Medications
    Complete list of current medications *If applicable
  • Insulin Prescription Form
    This form is only required when an insulin start is requested
  • Requester Information
    Please add the name, phone/fax, address, date of referral and signature

Mississauga Halton - Paediatric Referrals

Starting April 1, 2016, if you are referring a patient to the THP Paediatric Diabetes Management Centre please call the central intake number and send the referral form to the central fax. Upon receiving the referral form, the patient will be booked to see the Diabetes Care Team at either the Mississauga Hospital site or Credit Valley Hospital site based on staff and physician availability. You will be notified of the booking and your office will be responsible for advising the patient/family of the location and time of the appointment.

P: 905-813-1576 F: 905-813-4128