Assistance with Blood Glucose Level Monitoring Form-0067 Logo
  • ASSISTANCE WITH BLOOD GLUCOSE LEVEL MONITORING (Form-0067)

    Personal Care Services – Level 3 Approved Accreditation – Additional Fees and Charges Apply
  • Resident's Details

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  • REQUEST ASSISTANCE WITH BLOOD GLUCOSE LEVEL MONITORING

  • I request Skymac to assist me with monitoring my blood glucose (sugar) levels. In receiving this assistance, I understand that:

    • Skymac has provided me with a copy of the NDSS Blood Glucose Monitoring fact sheet explaining why, how, and when to monitor blood glucose levels.

    • I must provide Skymac with a copy of my Diabetes Care Plan given to me by my doctor or diabetes health professional, where available.

    • Skymac is authorised to store all my blood glucose level equipment in a locked and secure area.

    • Skymac will operate and maintain my blood glucose equipment according to manufacturer’s instructions.

    • Skymac will record my blood glucose levels at the times agreed upon by my doctor or diabetes health professional, or at the times stipulated in my Diabetes Care Plan.

    • If my blood glucose level is recorded as lower or higher than the levels recommended in my diabetes care plan, Skymac will follow the directions in my Diabetes Care Plan.

    • Skymac will monitor the expiry date for test strips, lancets and needles and reorder more when required.

    • Skymac may be advised by my doctor or diabetes health professional to prompt me to get bloods and other specimens when required.

    • Skymac will NOT administer any form of injection though will observe me when necessary.

    • Should I miss taking a reading at the times specified in my Diabetes Care Plan, or if I refuse, I do so at my own risk and Skymac may notify my doctor or diabetes health professional.

     

  • Signature of Resident

    *Or signature of person acting on authority under Guardianship Administration Act 2000 or Powers of Attorney Act 1998 for the person named above, OR an Informal Decision Maker (must have an Informal Decision Maker Details Form-0071 signed) for the person named above.
  • Clear
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  • In the Presence of (Witness)

  • Clear
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  • Should be Empty: