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 - a HbA1c 42-47mmol/mol (6.0%-6.4%) or FPG 5.5-6.9mmol/l reading within the last 24 months

Downloadable Version of Referral Form

The following forms are available for download to complete locally or import into your clinical system for autopopulation. These forms should be emailed using your email to

  • Microsoft Word – Download this form to complete manually and email.
  • SystmOne – Download this form and import into Referrals and Letters as a New Word Document
  • EMIS Web – Download this work and import into Templates, Letter Templates
  • Developer Version, MS Word – Download this form to create your own clinical system form or mailmerge with your own database

If you have any problems with this form please contact your local NDPP Regional Manager.