Outpatient Referral MVCC Oncology Consultant: Dr/Prof Hospital no: MVCC NHS patient: Yes No If private patient, are they having treatment at MVCC Yes No (Hal Gray Unit)? If NO the patient will need to get a letter of referral from their oncologist addressed to Hal Gray Reception, Mount Vernon Cancer Centre, Northwood, Middlesex, HA6 2RN. If unsure please speak to the healthcare professional on duty. If the answer to any of the questions above is YES, the patient/carer is eligible to use all LJMC services. Other private patients and NHS patients receiving treatment elsewhere may be able to attend relaxation classes, be offered the Therapy Network list and national programmes, eg, LGFB, HOPE etc. Please check if you are not sure. Details GP details Patient Carer First name: Last name: Name: Male Female Date of birth: Address: Address: Postcode: Home tel: Work tel: Postcode: Mobile tel: Can message Yes No be left? Do you claim travel costs* when coming for your hospital appointments? Do you use hospital transport? * Only applies to LJMC counselling appointments. We will try to schedule any complementary therapy appointments for the same day as hospital appointments if you prefer. Clinical details Diagnosis/site of disease: Current treatment (if any): Radiotherapy LA: Appt time: Date started: Date completed: Chemotherapy Date started: Date completed: Hormone treatment Ward: Other: Immunotherapy Person completing this referral form Name Position: (please print): Telephone: Date: Referred by (if different from above): Name: Position: Telephone: Please turn over to identify service is required
Outpatient Referral MVCC Oncology Consultant: Dr/Prof Hospital no: MVCC NHS patient: Yes No If private patient, are they having treatment at MVCC (Hal Gray Unit)? Yes No If NO the patient will need to get a letter of referral from their oncologist addressed to Hal Gray Reception, Mount Vernon Cancer Centre, Northwood, Middlesex, HA6 2RN. If unsure please speak to the healthcare professional on duty. If the answer to any of the questions above is YES, the patient/carer is eligible to use all LJMC services. Other private patients and NHS patients receiving treatment elsewhere may be able to attend relaxation classes, be offered the Therapy Network list and national programmes, eg, LGFB, HOPE etc. Please check if you are not sure. Details Patient Carer First name: Last name: Male Female Date of birth: Address: Postcode: Home tel: Work tel: Mobile tel: Can message Yes No be left? GP details Name: Address: Postcode: Do you claim travel costs* when coming for your hospital appointments? Do you use hospital transport? * Only applies to LJMC counselling appointments. We will try to schedule any complementary therapy appointments for the same day as hospital appointments if you prefer. Clinical details Diagnosis/site of disease: Current treatment (if any): Radiotherapy LA: Appt time: Date started: Date completed: Chemotherapy Date started: Date completed: Hormone treatment Ward: Other: Immunotherapy Person completing this referral form Name (please print): Position: Telephone: Date: Referred by (if different from above): Name: Position: Telephone: Please turn over to identify service is required
outpatient_referral_form.docx