Patient name:________________________Unit Number_____________________

Patient Telephone Number_____________Clinic:___________________________

PMD tel/beeper number______________Email address:____________________

MD address_____________________________________________________________

Reason for referral: (check one)

Appointments are made within 1-2 weeks of referral

______I. DM Education Class    Language________________

                Patient comes to 3 group classes: Diabetes 1 Overview Class, Nutrition 1

                and 2 Overview Class

                DM classes meet several times weekly in English and Spanish

______II. DM Team Consultation

                Patient will receive diabetes education followed by MD/NP appointment for

                management of diabetes.  Class attendance is mandatory to receive appointment.

Please list current patients medications here:

NBDM asks that the patient has had the following lab tests within 4 weeks of

appointment: Hgb A1c, fasting lipid profile, metabolic profile, LFT,

spot urine for microalbumin/creatinine, and EKG

Russ Berrie Medical Science Pavilion, 2nd floor
1150 St. Nicholas venue at 168th Street, New York, NY 10032
voice: 212-851-5455  fax 212-851-5459 email: diabetes @columbia.edu
http://cpmcnet.columbia.edu/dept/diabetes