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*

Health fund expiry date*

Member number*

Medicare card number*

Medicare card expiry date*

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
Homecare

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

No Page results for ‘’

No PDF results for ‘’

No News results for ‘’

Palliative Care referral form

Cabrini Palliative Care Referral

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