DIABETES REFERRAL FORM

To

Wini Schaedel, RN, MSN, ARNP/CNS, CDE

Certified Diabetes Educator

(785) 826-9257

 AT (Please circle appropriate clinic site)  

To make an appointment for “Diabetes Management and Education”

            Call the clinic number listed above

PLEASE FAX OR SEND A COPY OF THIS FORM AND THE PATIENT’S

RECENT LAB WORKUP TO:

Wini Schaedel, RN, MSN, CDE

(At appropriate clinic listed above)

(Labs:  Glucose, Lipid profile, Liver profile, Hgb A₁c, Microalbumin)

Please provide diabetes management and consultation services to:

            Patient’s Name:                                                                                                                       

            Home Phone #                                                                                                                        

            Work Phone #                                                                                                                         

            Address                                                                                                                                  

Diagnosis:                                                                                                                                            

Medications:                                                                                                                                        

Special requests:                                                                                                                                  

Physician’s Name and Signature                                                                                                           

            Phone                                                               Fax                                                                

            Address