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Health, Care and Education Professionals

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Specialist palliative care referral form

To find out how we use this information, our security and your rights visit our privacy page.

You will see a thank you page once the form has been submitted. If you do not see this page then you have overlooked to complete some of the required fields. Please check the form, complete the missing details and resubmit. Thank you.

Patient details

First name: *Required

Surname: *Required

Gender: *Required

Gender:

Male

Female

Date of birth: *Required

Date / Date of birth

Address: *Required

Post code: *Required

Ethnicity: *Required

Ethnicity:

White British

Gypsy/ Traveller/ Irish Traveller

Indian

Pakistani

Bangladeshi

Chinese

Other Asian

Asian British

Black or Black British

Mixed

Other ethnic group

Telephone number: *Required

NHS number: *Required

Place of care at present: *Required

Place of care at present:

Home

Hospital

Nursing Home

Residential Home

Patient lives alone: *Required

Patient lives alone:

Yes

What is the patients history with any holistic issues?

Patient has consented to referral:

Yes

Primary diagnosis(es) and key treatments:

Treatment is:

Curative

Palliative

Gold standards framework register (is the patient on the GP palliative care list?)

Allergies: (please specify)

Service requested: *Required

Service requested:

Community palliative care team

Hospital palliative care team

Day care

Hospice admission

Psychological/Social support

Carer support

Other

If other please specify:

Special consideration

First language if not English:

Communication in English

Good

Fair

Poor

Other barriers to communication: (e.g. hearing loss/confusion)

Would an interpreter be helpful?

Yes

Other considerations

Why has this referral been made for the patient?

Infection status:

Pressure areas:

Next of Kin/Main carer

Name: *Required

Telephone number:

Services involved

District nurse: *Required

District nurse:

Yes

Social services: *Required

Social services:

Yes

Care manager: *Required

Care manager:

Yes

Specialist nurse: *Required

Specialist nurse:

Yes

Team: (please specify)

Community matron: *Required

Community matron:

Yes

General practitioner

Name: *Required

Address: *Required

Post code: *Required

Telephone: *Required

PCT number:

DNACPR: *Required

DNACPR:

Completed

Not completed

Is referral urgent (assess with 2 working days)? *Required

Is referral urgent (assess with 2 working days)?

Yes

If urgent, please phone us for immediate advice

Inpatient details

Hospital:

Ward:

Date of discharge: (if known/planned)

Date / Date of birth

Is hospital palliative care team involved?

Yes

Consultant:

Telephone:

Extension:

Current issues/problems: (e.g. symptoms, psychosocial issues, insight)

Medication

SC infusion in progress: *Required

SC infusion in progress:

Yes

Transdermal patch:

Yes

Please attach medication list/TTO's:

Clinical correspondence attached:

Recent hospital letters

GP enhanced encounter form

Medication list/TTO's

Other

If other please specify:

Other comments: (e.g. insight, psychosocial issues)

Person completing this form

Name: *Required

Designation: *Required

Contact details: *Required

Location *Required

Date: *Required

Date / Date of birth

Email:

I agree to the privacy policy.

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Facilities and other info

Opening Times

Get in touch

By phone (general enquiries): 0300 123 3444

Via our customer experience team: MEDCH.customercare@nhs.net

Join our community forum: https://www.medwaycommunityhealthcare.nhs.uk/about-us/get-involved/community-forum

View our privacy notice: https://www.medwaycommunityhealthcare.nhs.uk/contact-us/privacy-notice

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