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Workshop Form

Thank you for your interest in attending our online “Understanding Diabetes and Prediabetes” Group.
Please tell us about yourself so that we can make sure that our group program will meet your needs.
All information will be kept confidential.

Understanding Diabetes Self-Referral Form

First Name *

Value is required and can't be empty

Last Name *

Value is required and can't be empty

Address

City *

Value is required and can't be empty

Province

Postal Code

Telephone Number *

Value is required and can't be empty

Email address

Date of Birth *

Value is required and can't be empty

Do you have a primary care provider?

YesNo

Please provide the name of your provider

What type of diabetes do you live with?

Type 2PrediabetesType 1I do not know

Do you take medication for diabetes?

YesNo

If your answer to previous question is yes, select all that applies

PillsInsulinOther injectable medication

Do you use an insulin pump?

YesNo

Have you recently started any steroid medication such as Prednisone or Cortisone?

YesNoI don't know

Are you checking your blood sugars?

YesNoSometimes

Have you recently (within the last month) had any low blood sugars (less than 4 mmol/L)?

YesNo

Are you pregnant or planning pregnancy?

NoYes, I am pregnantYes, I am planning pregnancyNot Applicable

Please specify your preferred gender identity:

Female

Male

Intersex

Trans – female to male

Trans – male to female

Two-Spirit

Do not know

Prefer not to answer

Other

A triage educator from our program will review your information and then someone from our program will call you.

I give permission for a triage educator to review my bloodwork through Connecting Ontario. This is to make sure I can receive the best service for my care. I understand that this information will be kept confidential.

YesNo

Is there anything else you would like to share with us?

Phone Number: (613) 233-6655

Fax Number: 613-233-6713

Email: [email protected]

We are a proud program of Centretown Community Health Centre

Office Location:

Centretown Community Health Centre
420 Cooper St.
Ottawa, Ontario
K2P 2N6