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Printed label may be placed here in place of written information
Type 2 Diabetes Program Discharge Referral Form
St Joseph Chronic Care Department 1600 Joseph Drive Bryan, TX 77802 Phone 979 821-7560 FAX 979 821-7587 Name: Phone numbers: Diagnosis: Please check all that apply 2777 Metabolic Syndrome 25000 Diabetes Type 2, not stated as uncontrolled 79021 Impaired fasting glucose Please fax results of the following labs if available: Fasting Glucose A1c Total Cholesterol 79029 Prediabetes 25002 Diabetes Type 2, uncontrolled Other DOB: 4 weeks, 1day a week, Comprehensive Diabetes Education coordinated by RN/Certified Diabetes Educator, Registered Dietitian
Triglycerides HDL LDL
Please list diabetes medications and dosage: _____________________________________________________________________________________ _____________________________________________________________________________________ Diabetes Counseling Program: Four-session program–One time per week over 4 weeks Blood glucometer and membership for one month in St Josephs Wellness Center included in the cost of the program Physicians Signature: Printed Physician Name: Physician Fax Number: _________________
Please
fax this form to 979 821-7587
Date: Phone :
09/25/2008
