SELF-REFERRAL FORM | diabetes-prevention

REGISTER YOUR DETAILS ONLINE

If you are a healthcare professional referring on behalf of a patient please ensure consent is gained before proceeding with the referral.

If your GP has sent you a letter or text which confirms that you are at risk of Type 2 diabetes, you are able to register for the Healthier You: NHS Diabetes Prevention Programme. To be able to register online you will need the following information found in your letter:

Your NHS number, latest HbA1c or FPG reading, including the date and your GP surgery name

These are required fields, and referrals without this information cannot be processed. To be eligible for this programme your HbA1c must be between 42-47 mmol/mol or Fasting Plasma Glucose between 5.5-6.9 mmol/l and dated within the last 12 months; or you have a history of Gestational Diabetes Mellitus (GDM) and normoglycaemia (HbA1c < 42 mmol/mol (< 6.0%) or FPG < 5.5mmol/l).

Please do not complete this form if you have already registered with Living Well Taking Control – registering a second time could delay your referral.

If you have been issued with a Participant ID (e.g. su4fum), this confirms your registration on to the diabetes prevention programme and you do not need to complete this form.

Please note that by submitting the form below, you are consenting to be contacted by Living Well Taking Control using the contact information you provide and that you have both read and agreed to our privacy policy.

Register for the programme online

Please note: if the registration form is submitted without all sections completed we will be unable to process your registration

First Name

Last Name

Date of Birth (please fill in using the format DD/MM/YYYY

Please provide your NHS Number (This is a 10-digit number unique to you, EG: 1234567890)

Street Address

Street Address Line 2

City/Town

Post Code

County

Best contact number

Which GP surgery are you registered with?

Preferred Language

Please input your FPG result (the eligibility criteria is 5.5-6.9mmol/l)

Please enter your Hba1c result

HbA1c Reading (please check above for eligibility criteria).

FPG Reading (please check above for eligibility criteria).

The Date You Had Your Blood Sugar Tested (DD/MM/YYYY)

If you are referring a patient on behalf of an organisation, please tell us which organisation you work for: (Please ensure you have the patient's verbal consent before referring them onto our programme). If you are refering yourself please answer N/A

Do You Have A History Of Gestational Diabetes?

Yes

Preferred Service Pathway

Digital one-one service

Face to Face Group Sessions