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: Profession	
Practice Name: Practice.Name	Practice Phone: Practice.Phone	
Address: Practice.Address	Email: Practice email	

Date: Miscellaneous.Date

Patient Details
RE: Patient Demographics.Full Name
DOB: Patient Demographics.DOB	Home Phone:  Patient Demographics.Phone (Home)  Mobile Phone: Patient Demographics.Phone (Mobile)	
Address: Patient Demographics.Full Address	Email: Patient Demographics.E-mail	
Language Preferred: Language preferred	NDSS number (if known): NDSS number	

Education Program/s Referral
Education Program/s

TYPE 1 DIABETES
DAFNE: 5 day interactive group program includes topics such as nutrition, carbohydrate counting, insulin dose adjustment, sick days and exercise.	DAFNE	
Pump Workshop: Basic skills workshop suitable for those considering a pumpor those wanting a refresher (18+, parents welcome).	Pump	
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.	One on One	
Junior, senior and family camps: Available around Queensland for young people with diabetes (external camp providers, costs may apply).	Camps	

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

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

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.