Provider Referral to Champlain Diabetes

Provider Referral to Champlain Diabetes Chiropody Services
Client Name: _____________________________________
Date: ____________________________
Client Phone: ____________________________________
Referring Provider: _____________________________________________
Request communication back?
Client has:
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Type 1 Diabetes
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Yes
□
No
Fax number: _____________________________
Type 2 Diabetes
REFERRAL ASSESSMENT
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Is client being treated for ulcer, sore, blister on feet at this time?
Yes
□
No
Is there infection present?
□ Yes □ No
If you answered yes, to either question, check URGENT
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Does client have any foot deformity, calluses or hard skin on feet?
Yes
□
No
Does client have any numbness, tingling, pins and needles, itching or burning sensations?
□
Yes
□
No
Does client have any tightness, heaviness, pain or cramps in feet or legs? □ Yes □ No
If you answered yes to one or more of these questions, check ONE-ON-ONE TREATMENT
If you answered no to all of the above questions, you may refer the client for registration in a GROUP FOOT
HEALTH EDUCATION (with foot screen).
REFERRAL FOR
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□
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Group foot health education session (with foot screen)
One-on-one treatment for advanced foot care management
Urgent: open wound and/or infection
Client would prefer to have chiropody assessment in:
o
o
o
o
o
o
o
East Ottawa (Vanier Parkway & Donald)
Downtown Ottawa (Somerset & Bank)
Nepean
Western Ottawa (Carling & Richmond)
Rockland
Carleton Place
Hawkesbury
o
o
o
o
o
o
Embrun
Cornwall
Beachburg
Pembroke
Lanark
Kemptville
Please Fax to: 613-233-6713
FOR OFFICE USE:
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Ottawa
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Community of Care
Renfrew County
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Eastern Counties
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North Lanark/Grenville
The Community Diabetes Education Program of Ottawa. Sponsored by Centretown Community Health Centre on behalf of
The Coalition of Community Health and Resource Centres of Ottawa. Funded by The Ontario Ministry of Health and Longterm Care.Programme communautaire d’éducation sur le diabète d’Ottawa. Parrainé par le Centre de santé communautaire
du Centre-ville au nom de la Coalition des centres de santé et de ressources communautaires d’Ottawa. Financé par le
Ministère de la santé et des soins de longue durée d’Ontario.