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Refer a patient

Specialist palliative care referral form - (copy)

Patient details
* required
* required
Gender * required


* required
   
* required
* required
Ethnicity * required












* required
* required
Place of care at present * required




Patient lives alone * required


Patient has consented to referral * required


Primary diagnosis(es) and key treatments
Treatment is * required




Service requested * required









Special consideration

Communication in English




Would an interpreter be helpful?




Next of Kin/Main carer
* required

* required
Services involved
District nurse * required


Social services * required


Care manager * required


Specialist nurse * required



Community matron * required


General practitioner
* required
* required
* required
* required

* required
DNACPR * required


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


If urgent, please phone us for immediate advice

Inpatient details
* required
* required

   
is hospital palliative care team involved? * required


* required
* required


Medication
SC infusion in progress * required


Transdermal patch




Clinical correspondence attached






Person completing this form
* required
* required
* required
* required
* required
   

Ashford: Pilgrims Hospice Telephone: 01233 504100 Email: PH.PilgrimsHospices@nhs.net Canterbury: Pilgrims Hospice Telephone: 01227 812612 Email: PH.PilgrimsHospices@nhs.net Dartford & Gravesham: Ellenor Lions Hospices Telephone: 01474 538508 Fax: 01474 326260 Maidstone: Heart of Kent Hospice Telephone: 01622 792200 Fax: 01622 718920 Medway & Swale: Wisdom Hospice Telephone: 01634 830456 Email: wisdom.hospice@nhs.net QEQM Hospital: Telephone: 01843 225544 Fax: 01843 220048 Thanet: Pilgrims Hospice Telephone: 01843 233920 Email: PH.PilgrimsHospices@nhs.net Tunbridge Wells: Hospice in the Weald Telephone: 01892 820500 Fax: 01892 820520 Email: clinical@hitw.org.uk William Harvey Hospital: Tel/Fax: 01233 616024 Kent & Canterbury Hospital: Telephone: 01227 766877 x 736 bleep 238 Darent Valley Hospital: Telephone: 01322 428293 Fax: 01322 428294 Maidstone Hospital: Telephone: 01622 225024 Fax: 01622 225116 Medway Maritime Hospital: Telephone: 01634 833807 Fax: 01634 833807 Email: wisdom.hospice@nhs.net Kent and Sussex Hospital: Telephone: 01892 632346 Fax: 01892 632939

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