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Diabetes Education
Diabetes Eye Screening Ottawa
Foot Care
Diabetes Central Ottawa
Diabetes Education
People living with diabetes
Healthcare providers
Diabetes Eye Screening Ottawa
English – Diabetes Eye Screening Ottawa
Français -Dépistage de l’oeil diabétique Ottawa
中文 – 渥太华糖尿病眼部筛查
Foot Care
For Clients
For Healthcare providers
Foot Care Referral Criteria
Self-Referral Forms
Diabetes Education
English – Self-referral form
Français – Formulaire d’auto-aiguillage
Diabetes Eye Screening Ottawa
English – Self-referral form
Français – Formulaire d’auto-aiguillage
中文 – 渥太华糖尿病眼部筛查 自行转介表格
Healthcare provider referral forms
Diabetes Education
Print and fax
Ocean eReferral
Diabetes Eye Screening Ottawa (DESO)
Print and fax
Foot Care
Print and fax
Foot care referral criteria
Diabetes Education – English – Self-referral form
I give permission for this form to be sent to one of the community-based diabetes education programs, so that they can contact me about my care. I understand that my information will be kept confidential.
*
Accept
Decline
I give permission for a triage 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.
*
Accept
Decline
Tell us a little bit about yourself so we can connect you to the right program: What type of diabetes do you have?
*
Type 2
Prediabetes
Type 1
I don't know
If you have type 1 diabetes please talk to your doctor about seeing a Diabetes Specialist.
Do you take medication for diabetes?
No
Yes (please select all that apply)
Pills
Insulin
Other injectable medication
Have you recently started any steroid medication, such as Prednisone or Cortisone?
No
Yes
I don't know
Do you use an insulin pump?
No
Yes
Are you checking your blood sugars?
No
Yes
Sometimes
Have you had any low blood sugars (less than 4mmol/L) recently?
No
Yes
Are you pregnant or planning pregnancy?
No
Yes I am pregnant
Yes I am planning pregnancy
N/A
If yes please talk to your doctor about seeing a Diabetes Specialist
Do you identify as Indigenous?
No
Yes
What type of service are you looking for? Are you looking for support with:
Education/Refresher
Blood sugars
Symptoms
Medications/Insulin
Nutrition
Other
Please indicate other types of services you are looking for:
Preferred language of service:
English
French
Other (enter below)
Other preferred language of service :
NAME
*
FIRST NAME(S)
LAST NAME
ADDRESS
Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Telephone #:
*
Other Telephone #:
When is the best time to call you?
Morning
Afternoon
Evening
Anytime
May we leave a voice message?
Yes
No
Please specify your preferred gender identity:
Male
Female
Intersex
Trans – female to male
Trans – male to female
Two-Spirit
Do not know
Prefer not to answer
Date of Birth:
*
DD
MM
YYYY
Where would you like to go to a program?
Near Home
Near Work/Other
Please specify work/other address:
Is there anything else you would like to share with us?
How did you hear about us?
