Diabetes Self-Management Class Referral Form

UNC Hospitals
Department of Medicine
Division of General Medicine
Enhanced Care Programs

Diabetes Self Management Education
Referral

Phone: 919-843-0391
Fax: 919-966-4507

Robb Malone, PharmD, CDE, CPP
Carrie Palmer, ANP
Amy Bouthillette, RD

Attention: Amy Bouthillette

This form can be completed by patients or providers. Please complete the form and click "send information". Items denoted with a red asterisk are required.
In some instances, a signed referral form is required. We will contact the Provider to obtain the necessary documentation.
We must speak to the patient before the appointment is scheduled. After receiving the referral, we will attempt to contact the patient

Date of referral:
Patient Last Name *:
Patient First name *:
Patient email:
MR #:
Date of birth *:	Select Date
Patient phone *:	(919) 555-1234
Address:
City:
State:
Zip:
Referring MD name *:
Referring MD phone *:
Services Requested (Check all that apply)
Carb Counting
Insulin start/teach
Meter teach
Diabetes Class- Overview
Special diet needs
Comments:

Please report problems and/or suggestions for this page to Jo Williams at jo_williams@med.unc.edu

The diabetes self management education class at UNC Internal Medicine follows the guidelines set by the American Diabetes Association. Ten key learning objectives are assessed pre-class and post-class. Individualized goals are set during class and reassessed during follow up visits.

Please direct additional questions and correspondence to diabetesclass@med.unc.edu