Palliative Care referral form

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Palliative & Supportive Care
Current: Palliative Care referral form

Palliative Care referral form

What is Palliative and Supportive Care?
Referring to our service
Our specialist Palliative Care Unit
Palliative care where you live
Palliative care across Cabrini
Supportive Outpatient Care Clinic
Resources

For referral to Cabrini Palliative Care the patient needs to have private health insurance or have the ability to cover the costs independently.

Complete the form below

Patient

First name (Patient) *

Surname (Patient) *

Date of birth (Patient) *

Gender (Patient) *

Country of birth (Patient) *

Address (Patient) *

Home contact number (Patient) *

Mobile number (Patient) *

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

If no, please explain why

Is patient aware of diagnosis/prognosis? *

Yes
No

Referring doctor details

Full name (Referring doctor) *

Type (Referring doctor) *

Specialist
General Practitioner

Provider Number (Referring doctor) *

Address (Referring doctor) *

Phone number (Referring doctor) *

Fax (Referring doctor) *

Medicare/Health insurance details

Does the patient have Private Health Insurance *

Yes
No

Health Fund Name *

Health Fund Number *

Medicare 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) *

Details of the person completing the referral document

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 Prahran
Community Palliative Care Service
Supportive care clinic

General Practitioner/Palliative Care Details

Full name (GP) *

Address (GP) *

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

Yes
No

Name of the Service *

Contact number of the service *

	General Enquiries (03) 9508 1222 admin@cabrini.com.au
	Emergency Department 24/7 (03) 9508 1500 183 Wattletree Road, Malvern
	Feedback (03) 9508 1661 crm@cabrini.com.au
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Palliative Care referral form

Complete the form below

Patient

Referring doctor details

Medicare/Health insurance details

Clinical details

Advance care plan

Details of the person completing the referral document

General Practitioner/Palliative Care Details

General Enquiries

Emergency Department 24/7

Feedback

Connect With Us