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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
Wound Care Chiropody
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 Eye Screening Ottawa – English – Self-referral form
Do you have a diagnosis of type 1 or type 2 diabetes?
(Required)
Yes
No
I don't know
Individuals must have a diagnosis of type 1 or type 2 diabetes to be eligible for a diabetic retinopathy eye screening.
Have you had a diabetic retinopathy eye exam within the past 12 months?
(Required)
Yes
No
I don't know
A retinal screening may or may not be included in an annual eye exam done by an optometrist. If you are unsure, please select “I don’t know”.
The DESO program can help you in languages other than English. If you prefer to speak another language, please let us know and we will book interpretation services:
Arabic
English
French
German
Italian
Mandarin
Cantonese
Punjabi
Hindi
Urdu
Polish
Portuguese
Spanish
Tagalog (Filipino, Pilipino)
Prefer not to answer
Please specify
Preferred language:
Name:
(Required)
First
Last
Date of Birth - please indicate below (Day/Month/Year):
(Required)
Day
Month
Year
Please specify your gender:
Male
Female
Intersex
Trans – Female to Male
Trans – Male to Female
Two Spirit
Do not know
Prefer not to answer
Please specify:
Gender:
Address:
Street 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 number:
Email (optional):
When is the best time to call you?
Morning
Afternoon
Evening
Anytime
May we leave a voice message?
Yes
No
Do you have a primary care provider (family doctor or nurse practitioner)?
Yes
No
Name of primary care provider:
Telephone number of primary care provider:
I give permission for this form to be sent to Diabetes Eye Screening Ottawa, so that they can contact me about a diabetic retinopathy eye screening. I understand that my information will be kept confidential:
(Required)
Yes
No
