Please note that Diabetes Services referrals are for patients 18 years of age and older.
The Central Intake Program is a single access point for managing referrals for Diabetes Services in Mississauga Halton.
Referral Process for Healthcare Professionals
Submit & Track Referrals through Central Intake eReferral. Register Here
Fax Referrals – (905) 338-0442
- Download the common referral form
- Complete the Diabetes Services Referral Form
- Fax only completed referrals to Fax: 1-855-338-0442
Self Referrals – (905)-338-2983 ext. 4872
Interested in attending a Diabetes Education Program, contact Central Intake to start the referral process. Once the self-referral has been initiated, your family doctor or other health care provider will be contacted to complete the process and the referral will be sent to the diabetes program. The Diabetes Education Program will contact you directly to schedule an appointment once they receive your referral.
Please note that the Central Intake Program will be unable to process incomplete referrals. Incomplete referrals will be sent back to the requesting practitioner for completion.
- Patient Demographics
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