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DIABETIC FOOT ULCER REFERRAL FORM Please complete all FOUR sections, ATTACH all related documents and FAX to the PC DSP at 5196456961. 1. PATIENT INFORMATION Affix LABEL or complete: 2. REFERRING
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How to fill out diabetic foot clinic referral

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How to fill out diabetic foot clinic referral

01
To fill out a diabetic foot clinic referral, follow these steps:
02
Obtain the referral form from the diabetic foot clinic or from the healthcare provider.
03
Fill in the patient's personal information, including their name, date of birth, and contact information.
04
Provide details about the patient's medical history, including any known diabetic complications and previous treatments.
05
Include relevant information about the patient's current condition, such as foot ulcers, infections, or any other symptoms or concerns.
06
Indicate any specific tests or examinations that the patient may require, such as blood tests, X-rays, or Doppler studies.
07
Mention any medications or treatments that the patient is currently undergoing or has recently completed.
08
If applicable, provide information about any previous referrals or consultations related to the patient's diabetic foot condition.
09
Sign and date the referral form, ensuring that it is legible and includes your contact information.
10
Submit the completed referral form to the diabetic foot clinic or the designated healthcare provider through the recommended channels.
11
Keep a copy of the referral form for your records.

Who needs diabetic foot clinic referral?

01
A diabetic foot clinic referral may be needed by individuals who meet the following criteria:
02
- Diabetic patients experiencing foot-related complications or concerns, such as foot ulcers, infections, neuropathy, or deformities.
03
- Individuals with diabetes who require specialized assessment and treatment for foot-related issues.
04
- Patients with diabetes who have been advised by their healthcare provider to seek consultation or treatment at a diabetic foot clinic.
05
- Those who have been referred by their primary care physician or healthcare team for diabetic foot care.
06
It is important to consult with a healthcare professional to determine if a referral to a diabetic foot clinic is necessary and appropriate for an individual's specific condition and needs.

What is Diabetic Foot Clinic Referral (Fax to 225-354-2075) Form?

The Diabetic Foot Clinic Referral (Fax to 225-354-2075) is a document needed to be submitted to the specific address to provide specific info. It must be completed and signed, which is possible in hard copy, or using a certain software e. g. PDFfiller. It helps to complete any PDF or Word document right in the web, customize it depending on your purposes and put a legally-binding e-signature. Right away after completion, you can send the Diabetic Foot Clinic Referral (Fax to 225-354-2075) to the relevant individual, or multiple recipients via email or fax. The template is printable too because of PDFfiller feature and options offered for printing out adjustment. In both electronic and physical appearance, your form will have a neat and professional look. You can also save it as the template to use later, there's no need to create a new file again. All that needed is to customize the ready template.

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Diabetic foot clinic referral is a process by which healthcare providers refer patients with diabetes who are at risk of foot complications to specialized clinics for comprehensive assessment, treatment, and management.
Healthcare providers, such as general practitioners, endocrinologists, and podiatrists, are typically required to file diabetic foot clinic referrals for patients who exhibit symptoms or risk factors for diabetic foot complications.
To fill out a diabetic foot clinic referral, a healthcare provider must complete a referral form that includes patient details, medical history, specific foot issues, and reason for referral, and then submit it to the appropriate diabetic foot clinic.
The purpose of diabetic foot clinic referral is to ensure that patients with diabetes receive specialized care to prevent serious foot problems, such as infections or amputations, and to manage any existing foot complications.
The referral must include the patient's demographic information, relevant medical history, details of foot conditions, current treatments, and specific concerns that need to be addressed by the diabetic foot clinic.
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