<p>West London Palliative Care Referral Form</p><p>Hillingdon Palliative Care Team Meadow House Hospice St Luke’s Kenton Grange Hospice (Hillingdon Hospital) (Ealing) (Harrow and North Brent) Tel: 01895 279412 Tel: 020 8967 5179 Tel: 020 8382 8001 Fax: 01895 279452 Fax: 020 8967 5756 Fax: 020 8382 8080 Harlington Hospice Michael Sobell House Trinity Hospice (Hillingdon) (Hillingdon) (Lambeth) Tel: 020 8759 0453 Tel: 01923 844302 Tel: 020 7787 1000 Fax: 020 8759 4652 Fax: 01923 844565 Fax: 020 7787 1067 Harrow Community Palliative Care Team Pembridge Palliative Care Centre St Johns Palliative Care Centre (St Luke’s Kenton Grange Hospice) (Kensington & Chelsea) (Westminster) Tel: 020 8382 8084 Tel: 020 8962 4410 Tel: 020 7806 4065 Fax: 020 8382 8085 Fax: 020 8962 4407 Fax: 020 7806 4041 (PLEASETICK) PLEASE SEND COPIES OF RECENT CLINICAL CORRESPONDENCE WITH THIS FORM PLEASE PRINT CLEARLY AND USE BLACK INK Patient Details</p><p>Surname Male/Female Patient consent to Office use </p><p>First Name Palliative Care</p><p>Address involvement</p><p> Yes  No Postcode Tel Mobile Tel Is GP aware of referral? Marital Status Ethnicity</p><p>NHS No DoB Age  Yes  No Primary diagnosis(es)</p><p>Communication First Language if not English: Communication in English Good Fair Poor (please circle) Would interpreter be helpful to patient and Palliative Care staff?  Yes  No Other barriers to communication e.g. hearing loss, confusion</p><p>Next of Kin/Patient District Nurse Yes  No  General Practitioner Representatives Name Name Name Address Based at Address Telephone Telephone Fax Relationship to patient Postcode Main Carer (if different from above) Social Services Yes  No  Telephone Name Name Telephone Based at Fax/email Relationship to patient Tel Fax Continuing care assessment completed: Yes/No PCT number: Reason for Referral – please tick Service required – please tick Patient is currently – please tick  Pain/symptom control  Home assessment and support  at home  Emotional/psychological support  Hospital assessment  in hospital (see over)  Social/financial  Admission (circle)  elsewhere (e.g. Nursing Home)  Assessment for hospice admission respite/symptom control / terminal care  Carer support  Day Care Does patient live alone  Yes  No  Other reason e.g. (spiritual, lymphoedema) _ Outpatient assessment Patient Mobility: </p><p>IS REFERRAL URGENT (assess within 2 working days)?  Yes  No IF URGENT, PLEASE PHONE US FOR IMMEDIATE ADVICE West London Palliative Care Referral Form</p><p>PATIENT NAME ………………………………………………. In-Patient details Hospital Telephone Ward Direct Ward Ext. Date of discharge (if known) Consultant (1) Consultant (2) Name and tel no. of key Hospital Palliative Care nurse and team: MRSA Status  Positive  Negative Not known </p><p>Name and tel no. of community Palliative Care nurse and team: </p><p>Brief History of diagnosis(es) and Key treatments Date Progression of disease and investigations/treatment Consultant and hospital</p><p>Current problems 1. 4.</p><p>2. 5.</p><p>3. 6.</p><p>Referrer’s expectation of current treatment (circle) symptom control / life prolonging / curative</p><p>Estimated prognosis (circle) days / weeks / months / years </p><p>Current Past Medical and Psychiatric History Medication/Allergies</p><p>Insight Has patient been told diagnosis?  Yes  No Is the carer aware of patient’s diagnosis?  Yes  No Does patient discuss the illness freely  Yes  No Can we write to GP?  Yes  No Any other comments/information</p><p>Please ensure patients are aware information will be held on computer according to the Data Protection Act.</p><p>Referrer’s signature: Name: (please print) Job title: Contact number: Bleep no: Surgery or Hospital: Date: West London Palliative Care Referral Form FAX</p><p>Date: ______</p><p>Number of pages including cover sheet: ______</p><p>To: ______From: ______</p><p>______</p><p>______</p><p>Fax No: ______Phone No. ______</p><p>Fax no: ______</p><p>Catchment areas of palliative care centres by PCT (Primary Care Trust)</p><p>PCT (Local Authority) Main Palliative Care Options </p><p>Brent Pembridge Palliative Care Centre, St John’s Palliative Care Centre, St Luke’s Kenton Grange Hospice</p><p>Ealing Meadow House Hospice</p><p>Hammersmith & Fulham Pembridge Palliative Care Centre, Trinity Hospice</p><p>Harrow Harrow Community Palliative Care Team, Michael Sobell House, St Luke’s Kenton Grange Hospice</p><p>Hillingdon Hillingdon Palliative Care Team, Michael Sobell House</p><p>Hounslow Meadow House Hospice</p><p>Kensington & Chelsea Pembridge Palliative Care Centre, Trinity Hospice</p><p>Westminster St John’s Palliative Care Team, Pembridge Palliative Care Centre, Trinity Hospice</p><p>N.B. St John’s Hospice provides an HIV service to all PCTs.</p>