The North London Palliative and Supportive Care Network Referral Form

THE NORTH LONDON PALLIATIVE AND SUPPORTIVE CARE NETWORK Referral Form (Please Tick)

Barnet Community – See North Islington EliPSe (End of Life & Palliative St Johns Hospice * London Hospice Care Service) Team In patient Barnet Hospital Macmillan Palliative Tel: 020 3317 5777 Hospice at Home Care Support Team Fax: 020 7607 3995 Community Tel: 020 8216 4446 Day Care Fax: 020 8216 4409 Marie Curie Hospice Hampstead Tel : 020 7806 4040 Day Therapy Unit / Outpatient Unit Fax: 020 7806 4041 Chase Farm Hospital Macmillan Tel: 020 7853 3430/29 Palliative Care Support team Fax 020 7853 3438 St Josephs Hospice* Tel: 020 8375-2384 Inpatient Unit In Patient Fax: 020 8375-1070 Tel 020 7853 3400 Community team Fax 020 7853 3437 Day Care Camden PCT and UCLH Palliative Tel: 020 8525 6084 Care Team The North London Hospice: Fax 020 8525 6085 Hospital Support Team Inpatient Unit Community Community Team St Clare Hospice Tel: 0203 447 7140 Day Care In Patient Fax: 0203 447 7677 Tel: 020 8343 8841 Community team Fax:020 8343 7672 Day Therapy Enfield Community Palliative Care Tel: 01279 773773 Team The North Middlesex Hospital Palliative Fax 01279 771771 Tel: 020 8367 4099 Care Team Fax: 020 8366 9810 Tel: 020 8887 2475 Princess Alexandra Hospital Macmillan Fax: 020 8887 4237 Palliative Care Team (Harlow) Haringey Palliative Care Team Tel: 01279 827846 Tel: 020 8275 4100 The Royal Free Hospital Palliative Care Fax: 01279 827378 Fax: 020 8275 4080 Support Team Hospital Support Team Whittington Health Palliative Care Service: Harley Street Clinic, Palliative Care Community Hospital Support Team Team Tel: 020 7830 2905 Tel: 020 7288 5227 Tel: 020 7935 7700 Bleep 54 Fax: 020 7830 2045 Fax: 020 7288 5788 Fax: 020 7486 2887 * please note these services are not in the network but will accept referrals on this form PATIENT DETAILS (in capitals please) NEXT OF KIN / MAIN CARER SURNAME…………………………………………………………………………...TITLE………………………… NAME………………………………….………...

FIRST NAME………………………………………………………………… MALE / FEMALE…………… RELATIONSHIP TO PT………………………...

ADDRESS……………………………………………………………………………………………………………… ADDRESS………………………………………..

……………………………………………………………………………POSTCODE……………………………… …………………………………………………… POSTCODE…………...………………………… TEL……………………………………………………… MOBILE………………………………………………… TEL………………………………………………. MARITAL STATUS……………………….. DOB…………………………………………. AGE………………… MOBILE………………………………………… NHS NUMBER (If Known)……………………………………………………….

PRIMARY DIAGNOSIS………………………………………………………………………………………….. IS PATIENT AWARE OF DIAGNOSIS YES / NO

DATE OF DIAGNOSIS……………………………………………………………………. ……………………. IS PATIENT AWARE OF REFERRAL YES / NO GP DETAILS HOSPITAL DETAILS

HOSPITAL………………………………………………………………………….. NAME……………………………………………………………………………... CONSULTANT…………………………………………………………………….. ADDRESS………………………………………………………………………… TEL……………………………………. HOSPITAL NO…………………………. …………………………………………………………………………………….. HOSPITAL…………………………………………………………………………. POSTCODE………………………………. TEL………………………………… CONSULTANT…………………………………………………………………….

PCT……………………………………….. FAX………………………………. TEL……………………………………. HOSPITAL NO…………………………. IS GP OR CONSULTANT AWARE OF REFERRAL YES / NO REFERRED BY…………………………………………………………………… REFERRED FOR: 1 Community Support Team/ Inpatient / Outpatient / Day Care / TITLE……………………………………DATE OF REFERRAL………………. Hospice at Home (Delete) SYMPTOM CONTROL CONTINUING CARE CONTACT DETAILS……………………………………………………………. RESPITE REHABILITATION ……………………………………………………………………………………

2 PALLIATIVE CARE TEAM OTHER SERVICES / PROFESSIONALS / INFORMAL SUPPORT PATIENT RECEIVES AT HOME (please indicate contact numbers and NAME …………………………………………………………………………….. frequency of visits where known) ……………………………………………………………………………………… BASED AT………………………………………………………………………… ……………………………………………………………………………………… TEL…………………………………… FAX…………………………………….. ……………………………………………………………………………………… DISTRICT NURSE ……………………………………………………………………………………… NAME……………………………………………………………………………. ……………………………………………………………………………………… BASED AT……………………………………………………………………….. ……………………………………………………………………………………… TEL…………………………………… FAX…………………………………….

HISTORY OF ILLNESS AND TREATMENT and PAST MEDICAL HISTORY (please enclose copies of relevant medical letters, blood results and investigation results) ………………………………………………………………………………………………………………………………………………………………………………….

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CURRENT PROBLEMS ………………………………………………………………………………………………………………………………………………………………………………….

HAS CPR BEEN DISCUSSED WITH THE PATIENT? YES / NO IF YES: CPR Status …………………………………………………………..

ALLERGIES……………………………………… Oxygen requirements YES / NO MRSA (or other Hospital Acquired Infection) ……………………………………………………… if yes:details………………………………………….. ……………………………………………………….

MEDICATION NAME OF DRUG DOSE FREQUENCY NAME OF DRUG DOSE FREQUENCY

…………………………………………………………………………………. ………………………………………………………………………………….

WHERE IS THE PATIENT AT PRESENT (PLEASE TICK)

AT HOME IN HOSPITAL……………………………. WARD……………………….

ELSEWHERE (e.g. nursing home)…………………………………………..... TEL NO………………………… DISCHARGE DATE………………………

NAME OF PATIENT……………………………………. DATE OF BIRTH………………………… 3 SOCIAL, CULTURAL AND SPIRITUAL ISSUES (please include who the LANGUAGE SPOKEN……………………………………………………… patient lives with and details of children under 18) INTERPRETER REQUIRED YES / NO …………………………………………………………………………………. DETAILS OF ANY RISK FACTORS FOR STAFF WHEN CARING FOR …………………………………………………………………………………. THIS PATIENT

…………………………………………………………………………………. ………………………………………………………………………………….

ANY ADDITIONAL INFORMATION

FOR OFFICE USE ONLY

Please fax or send completed referral form to the appropriate team. If Faxing please send on hard copy when possible Please ensure that you send enclose copies of relevant medical letters, blood results and investigation results Unfortunately if the form is not fully completed this may delay response.

NAME OF PATIENT……………………………………. DATE OF BIRTH…………………………