Diabetes HCP | Central Intake Program

Diabetes Education and Care Services

Healthcare Providers

Download the Common Referral Form

Complete the Diabetes Services Referral Form

Fax only completed referrals to Fax: 1-855-338-0442

Patient Information: Name, DOB, Address, Phone Number, Health card Number

Diabetes Diagnosis: Clearly indicate the type of diabetes (i.e. Type 1, Type 2, Pre-diabetes, Gestational Diabetes or Steroid-induced)

Assessment Data: HbA1C & eGFR are required within the last 12 months

Current Diabetes Medications: Complete list of current diabetes 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, billing number

LIVE! Primary care providers can submit referrals through Oceans. Find us on the Ocean Health map under Mississauga Halton Adult Diabetes Services.