Self-Referral Form
This self-referral form is intended for individuals who are 18 years of age or older, live in Ottawa, and are living with diabetes or prediabetes.
FIRST NAME(S) *
May we leave a voice message when we call you?
Do you have a primary care provider (a family doctor or nurse practitioner)?
1.Have you been diagnosed with prediabetes or diabetes?
2. Do you take medication for diabetes?
3. Have you recently started any steroid medication such as Prednisone or Cortisone? (not including eye drops or topical creams) *
4. Are you checking your blood sugars? *
5. Have you recently (within the last month) had any low blood sugars (less than 4 mmol/L)? *
6. Are you pregnant or planning pregnancy? *
A diabetes educator from our program will review your information and then someone from our program will call you.
I give permission for a diabetes educator to review my bloodwork through Connecting Ontario. This is to make sure I can receive the best service for my care. I understand that this information will be kept confidential *
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