ESSENTIAL PATIENT DETAILS Referral Date: Surname: Male Female DOB: First Name: as: Age: Address: Town: Ethnic status County: White British Bangladeshi Other black Postcode: Mixed white/ White Irish Other white black Caribbean Telephone: Mixed white/black African Pakistani Email: Mixed white Asian Other mixed Asian NHS No. Indian Black African Black Caribbean Hospital No. Chinese Not stated Marital status: Married Single Civil partnership Divorced Widowed Co-habiting Separated Next of Kin/Patient representatives General Practitioner Surname: Name: First Name: Surgery: Address: Postcode: Telephone: Postcode: Fax: Telephone: Secure email: Email: GP aware of referral: Yes No If please inform GP “No” Relationship to patient: Community Nursing Services Name: Main Carer (if different from above) Based at: Surname: Telephone: Name: Fax: Address: Hub email: Continuing Care funding in place Yes No Postcode: Any communication difficulties: Telephone: Email: Relationship to patient: Key reason for referral Service Requested The patient is currently Pain/symptom management Assessment in home……………………….. At home……………………………………. ………… Emotional/psychological support……. Day Hospice care……………………….…... In hospital……………………………….…. Social/financial………………………… Admission to Hospice………………………. Other care setting ………………………... Carer support Assessment Community Hospital…………. (please state where) …………………………. Other reason ………………………….. Hospital/community professional If in hospital, please complete the following: Involved with patient’s care: Name: Ward: Date of discharge: Based at: Direct Ward Ext: Is hospital Palliative care team involved? Yes No Telephone: Direct telephone: If please consider review by the “No” Fax: Consultant: Hospital Palliative Care Team MRSA/C. difficile/other status: Positive Negative Not known Specify: Diagnosis and relevant clinical history Does the patient have capacity Yes No Has the patient consented to this referral Yes No
ESSENTIAL PATIENT DETAILS Referral Date: Surname: Male as: Female DOB: Age: First Name: Address: Town: Ethnic status County: White British Bangladeshi Other black Postcode: Mixed white/ black Caribbean White Irish Other white Telephone: Mixed white/black African Pakistani Email: Mixed white Asian Other mixed Asian NHS No. Indian Black African Black Caribbean Hospital No. Chinese Not stated Marital status: Married Single Civil partnership Divorced Widowed Co-habiting Separated Next of Kin/Patient representatives General Practitioner Surname: Name: First Name: Surgery: Address: Postcode: Telephone: Postcode: Fax: Telephone: Secure email: Email: GP aware of referral: Yes No If “No” please inform GP Relationship to patient: Community Nursing Services Name: Main Carer (if different from above) Based at: Surname: Telephone: Name: Fax: Address: Hub email: Continuing Care funding in place Yes No Postcode: Any communication difficulties: Telephone: Email: Relationship to patient: Key reason for referral Service Requested The patient is currently Pain/symptom management ………… Emotional/psychological support……. Social/financial………………………… Carer support …………………………. Other reason ………………………….. Assessment in home……………………….. Day Hospice care……………………….…... Admission to Hospice………………………. Assessment Community Hospital…………. At home……………………………………. In hospital……………………………….…. Other care setting ………………………... (please state where) Hospital/community professional Involved with patient’s care: If in hospital, please complete the following: Name: Based at: Telephone: Fax: Ward: Direct Ward Ext: Direct telephone: Consultant: Date of discharge: Is hospital Palliative care team involved? Yes No If “No” please consider review by the Hospital Palliative Care Team MRSA/C. difficile/other status: Positive Negative Not known Specify: Diagnosis and relevant clinical history Does the patient have capacity Yes No Has the patient consented to this referral Yes No
midhurst-macmillian-specialistreferral.docx