Are you a GP or nurse who wants to
refer your
patient?

Your patient is eligible for this service if they meet all of the following criteria:

• Aged 18 years or over
• Not currently pregnant
• Have non-diabetic hyperglycaemia (NDH)- a HBA1c 42-47mmol/mol (6.0-6.4%) or a Fasting Plasma Glucose 5.5-6.9mmol/l reading taken within the last 12 months
• Individuals with a history of Gestational Diabetes Mellitus are eligible (with a blood reading of HbA1c < 42 mmol/mol or FPG < 5.5mmol/l within the last 12 months)

Downloadable Version of Referral Form

The following form is available for download. This form should be emailed using your nhs.net email to WHUB.Ingeus-NDPP@nhs.net

• Microsoft Word – Download this form to complete manually and email.

If you have any problems or need a form to import into your clinical system such as Systm One or EMIS web please contact your local NDPP Regional Manager.