Diabetes Care Ealing - Right Start Referral

Right Start - Diabetes Type 2 Education Learning

Right Start is an interactive education programme for people with type 2 diabetes, which involves our diabetes specialist dietitians, podiatrists and diabetes specialist nurses. The programme is designed to help you understand your condition, and to increase your confidence in managing your diabetes. It's free if you are registered with a GP in Ealing only. Choose to make the Right Start for your health now, by completing and submitting the form down below.
Please check that you fit all our referral criteria before completing the rest of this form

* Diagnosed with Type 2 diabetes

* Registered with a GP and living in the Ealing Borough

* Participate in all face to face (English or Punjabi) or online (English only) group education sessions (usually made up of between 3 or 4 sessions each running for approx. 2 hours)

* The online sessions are delivered digitally via Microsoft Teams, you will need access to a laptop, smart phone or tablet

- Please note we do not provide any transport or arrange for interpreters

Patient Information
Name*

Prefix, e.g. Mr./Mrs./Ms. First NameSurname
Date of birth*

DayMonthYear
enter date of birth
NHS Number *
enter NHS no if known
Address*

Street Address

Street Address Line 2

Town/City Borough/County

Postcode
I live and I am registered with a GP in the Borough of Ealing*

YesNo
Phone Number*

enter Area Code +44enter landline or mobile phone number
Email
example@example.com
I have Type 2 Diabetes*

Yes
Patients with impaired glucose/borderline diagnosis can through their GP, join the National Diabetes Prevention Programme - Website: https://www.england.nhs.uk/diabetes/diabetes-prevention/
Date of diabetes diagnosis *
If exact date not known, please give approximate month and year of diagnosis
Last HbA1c
enter last HbA1c if known
Weight (if known)
in kilograms
Height (if known)
in cm or feet

Preferred session and consent
My preferred Session*

Face to face (English)Face to face (Punjabi)Online (English)
Who completed this form?*

PatientHealth ProfessionalOther (please specify)
Date*

DayMonthYear
Date when e-form completed
Thank you! By completing and submitting this form you give consent to be referred to our Diabetes Education Service and allow us to contact your GP to acquire relevant information to complete your referral if necessary. We aim to contact you within 7 working days to make booking arrangements.

Enquiries: 0203 830 5810 (Mon-Fri 09:00 - 12:00)
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Right Start - Diabetes Type 2 Education Learning