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CCDC: Centre for Complex Diabetes Care

Referral Form

Branson Ambulatory Care Centre




555 Finch Avenue West Toronto, ON M2R 1N5
Tel: 416-635-2575
Fax: 416-635-2601


You can also download and fax the form from here: Download Form
Download CCDC Brochure


Patient Information

Last Name: *
First Name: *
Address: *
Postal Code: * -
Gender: *
DOB: * Day: Month: Year:
Spoken Language: *
Email:
Telephone: * ( )- -
Business: ( )- -
Cell: ( )- -
HealthCard Number: - - -
No Coverage
Impaired Mobility: Requires wheelchair, cane, walker, etc

Type of Diabetes

Diagnosis: *

Reason for Referral

Reason for Referral: * Unmanaged Diabetes Complications
Barriers in accessing health care (eg. serious mental illness/mobility/frail elderly)
Comorbidities which impact glycemic control
Recurrent Hospitalization/ER visit
Complexity Requiring CASE MANAGEMENT
Please provide details or specific concerns to be addressed:


Medications & Labs

Please list or attach current medications, recent lab work, and other relevant information.



Attachment(s)


CCDC Care is inter-professional and concurrent along with the Primary Care Provider.
A plan of care is established focusing on patient specific goals and patients will be transitioned to a Diabetes Education Centre (DEC) as needed, when appropriate.



Referring Physician/Healthcare Provider Information

First Name: *
Last Name: *
Primary Telephone: * ( )- -
Fax: ( )- -
Email:
Billing#:
Address:

Consent:


Primary Care Physician Information

Same as Above
First Name:
Last Name:
Primary Telephone: ( )- -
Fax: ( )- -