Palliative Care referral form

Patient Details

Client's name*

First Last

DOB*

Gender*

Male
Female

Country of birth*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone number*

Full name (Primary carer/next of kin)*

Contact number (Primary carer/next of kin)*

Relationship to the patient*

Current location of care*

Is this person currently in hospital?*

Yes
No

Date of admission*

Date of planned discharge*

Has the patient given permission for this referral to be made?*

Yes
No

Is patient aware of diagnosis/prognosis?*

Yes
No

Referring doctor details

Referring doctor's name*

First Last

Type (Referring doctor)*

Specislist
General Practitioner

Provider Number (Referring doctor)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone number*

Medicare/Health insurance details

Does the patient have Private Health Insurance*

Yes
No

Health Fund name

Member number

Exp. date

Medicare card number

Clinical details

Primary Diagnosis*

If cancer – state sites of metastatic disease

Date of diagnosis*

Reason for referral*

Describe presenting symptoms, psychosocial issues, current treatment

Allergies*

Relevant social history

Does the patient live alone?*

Yes
No

Any communication considerations? i.e. sight, hearing, speech deficiencies*

Does the patient have specific cultural needs? (i.e. food, language etc)

Do they need an interpreter?*

Yes
No

Language(s) spoken*

Advance care plan

Has the patient completed an advanced care plan?*

Yes
No

Is there a nominated medical treatment decision maker?*

Yes
No

Full name (Medical treatment decision maker)*

Contact Number (Medical treatment decision maker)

Full name (Medical treatment decision maker)

Full name (Person completing this form)*

Contact number (Person completing this form)

Role of the person completing this form e.g. liaison nurse/GP*

Select the service(s) the patient requires*

Inpatient care
Supportive outpatient care clinic

General Practitioner/Palliative Care Details

Full name (GP)*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is the patient currently being cared for by a community palliative care service?*

Yes
No

Name of the Service

Contact number of the service

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Palliative Care referral form

Patient Details

Referring doctor details

Medicare/Health insurance details

Clinical details

Advance care plan

Full name (Medical treatment decision maker)

General Practitioner/Palliative Care Details