Community Specialist Palliative Care

Community Specialist Palliative Care Team Referral Form

Mr/Mrs/Ms/Miss/Other: NHS Number: Surname: Marital Status: Ethnic Group: Forenames: Next of Kin/Carer:

Known as: Relationship: DOB: Age: M / F Contact Number: Address: Referrer Name:

Designation/Place of Work: Postcode: Telephone: Telephone:

Lives Alone Y / N Date of Referral: GP: Consultant: DN: Other: Current Location of Patient: Is the patient aware Is GP aware of this of this referral? Y / N referral? Y / N Diagnosis: Site of any Metastases (if applicable)

Date of Diagnosis: Reason for Referral: ☐ Other please state: ☐ Pain ☐ Terminal Care ☐ Emotional/Psychological Support Urgent (contact within 2 working days) ☐ ☐ Symptom Control (please specify below) Routine (contact within 7 days) ☐ Main Symptoms/Problems:

Any Other Relevant Information:

In the event that all information is not supplied we will need to contact you which may result in a delay. Updated 12/07/16 DH