National Diabetes Services Scheme (NDSS)
Program Referral Form

Please return completed form to Diabetes Queensland via one of the options below:

Medical Objects:
QUEENSLAND NDSS PROGRAMS DIABETES (QD40640000Z)

Fax: 1300 536 953

Questions: Contact us on 1300 136 588 or events@diabetesqld.org.au

Program Details
Diabetes Queensland, as agent of the National Diabetes Services Scheme (NDSS) in Queensland, delivers a comprehensive range of courses and workshops throughout Queensland at no cost to NDSS registrants.
To refer your eligible patients/clients to a program in their area, please complete and forward the following form. Diabetes Queensland will then contact your patient/client and provide them with information on the available programs. 

Referring General Practitioner/Health Professional
Name: <<Miscellaneous:Current User>> | Profession: <<Referrer's Profession>>
Practice Name: <<Practice:Name>> | Practice Phone: <<Practice:Phone>>
Address: <<Practice:Address>> | Email: <<Practice:E-mail>>

Date: <<Miscellaneous:Date (short)>>

Patient Details

RE: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>

Phone:
Home <<Patient Demographics:Phone (Home)>>  Mobile <<Patient Demographics:Phone (Mobile)>>

Address: <<Patient Demographics:Full Address>> | Email: <<Patient Demographics:E-mail>>
Language preferred: <<Patient Demographics:Language Preferred>> | NDSS number (if known): <<Patient NDSS number (if known)>>

Education Program/s Referral
<<Education Program/s>>

TYPE 1 DIABETES 
DAFNE: The 5-day interactive group program includes topics such as nutrition, carbohydrate counting, insulin dose adjustment, sick days and exercise. | <<Type1 DAFNE 5 day interactive group program>>
Pump Workshop: Basic skills workshop suitable for those considering a pump, or those wanting a refresher (18+, parents welcome). | <<Type1 Pump Workshop (18+, parents welcome)>>
Type 1 diabetes family seminar: Parents and carers will learn strategies to help support their young person with type 1 diabetes through the teenage years. | <<Type1 One on One family seminar (teenage yrs)>>
Junior, senior and family camps: Available around Queensland for young people with diabetes (external camp providers, costs may apply). | <<Type1 Junior, senior and family camps>>

TYPE 2 DIABETES
DESMOND: 1 day self-management course covering the basics of diabetes, monitoring, complications and goal setting. | <<Type2 DESMOND 1 day self-management course>>
MedSmart: 2 hour interactive workshop to help individuals understand the medications they are using to treat their diabetes. | <<Type2 MedSmart 2 hour interactive workshop>>
MeterSmart: 2 hour practical workshop on blood glucose monitoring: when to check, why to check and how to interpret their results. | <<Type2 MeterSmart 2 hour practical workshop>>
CarbSmart: 3 hour practical information on carbohydrate choices and how they affect blood glucose levels. | <<Type2 CarbSmart 3 hour practical info on carbs >>
Living with Insulin: 3 hour workshop for those with type 2 diabetes new to insulin or wanting a refresher. | <<Type2 Living with Insulin 3 hour workshop>>

TYPE 1 & TYPE 2 DIABETES
ShopSmart: 3 hour workshop on understanding food labels and making healthy food choices when shopping. | <<Type1/2 ShopSmart 3 hour workshop>>
FootSmart: 2 hour practical workshop that teaches how to check and care for their feet. | <<Type1/2 FootSmart 2 hour practical workshop>>
ReadySet Go, Let's Move: 3 hour workshop to help individuals get active and stay on track. | <<Type1/2 ReadySet Go, Let's Move 3 hour session>>

Privacy statement: Diabetes Queensland is collecting your information to register your selected NDSS education program. Diabetes Queensland is the National Diabetes Services Scheme (NDSS) agent in Queensland. As the NDSS agent for Queensland, any personal information we receive as agents of the NDSS is handled in accordance with the NDSS Privacy Policy. To view the NDSS Privacy Policy, please visit www.ndss.com.au or call 1300 136 588.