Get Champlain Diabetes Chiropody Program Referral Form - Champlaindrcc

Filling out the Champlain Diabetes Chiropody Program Referral Form is a crucial step in facilitating the care of individuals with diabetes. This guide provides comprehensive instructions to help users accurately complete the form online, ensuring seamless referrals.

Follow the steps to effectively complete the referral form.

1. Click the ‘Get Form’ button to access the referral form online and open it in your preferred document editor.
2. Begin by entering the referring provider's information. Fill in the provider's name, phone number, and required fax number. Indicate whether communication regarding the referral is requested by selecting ‘Yes’ or ‘No’.
3. Proceed to the client information section. Enter the client's name, select their gender (Male or Female), and provide the date of birth in the specified format (DD/MM/YYYY). Include the client's phone number and an alternate contact number.
4. Identify the language preference for the client by selecting from the options: English, French, or Other. Additionally, indicate the type of diabetes for which the referral is being made (Type 1, Type 2, or Pre-Diabetes). You can also select if the referral is for a Chiropodist assessment or group health education.
5. Next, assess the client's condition by selecting any relevant medical issues. Options include loss of sensation, presence of callus or corns, past foot ulcers, absent pedal pulse, or the need for education on proper diabetic foot care.
6. If the client requires an urgent appointment, indicate this by checking the appropriate box and providing details regarding any immediate concerns, such as open wounds or infected ingrown toenails.
7. Choose the preferred appointment location from the provided options, which include various sites across Ottawa and surrounding areas.
8. Once all sections of the form are completed, review the information for accuracy. After confirming the details, you can choose to fax the completed referral to the designated number (613-233-6713), or you may save changes, download, or print the form for your records.

Complete the Champlain Diabetes Chiropody Program Referral Form online today to ensure timely and effective care for clients.