Get in Touch For Medical Professionals 2219 Bath Street, Santa Barbara, CA 93105 (805) 682-4793 info@sansum.org Diabetes and Pregnancy Referral Patient Name* First Last Birthday (MM/DD/YYYY)*Due DatePhone*Today's Date* Date Format: MM slash DD slash YYYY Preferred Language*EnglishSpanishReason for Referral*Dr. Castorino Diabetes and Pregnancy team management (evaluate and treat)Weekly group Diabetes and Pregnancy educationEvaluate for research opportunitiesPreconception planningType of DiabetesGDMType 1 DiabetesType 2 DiabetesPrediabetesMost recent A1CPlease enter a number from 0 to 20.0.Date of most recent A1CCurrent insulin use?YesNoCurrent devices?Other relevant history? Sansum diabetes research institute Additional Referral Forms DSMES (Diabetes Self-Management Education and Support) DPP (Diabetes Prevention Program) Resources Current clinical research trials at SDRI Type 1 Diabetes programs Type 2 Diabetes programs Prediabetes Diabetes in Pregnancy The Complete Guide for Pregnancy Planning with Type 1 Diabetes from JDRF