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HARTLEPOOL & DISTRICT HOSPICE REFERRAL FORM
DATE OF REFERRAL:……………………..
Name of person completing form:...... Signature......
Designation:……………………… Organisation ...... Contact Number......
Patient known to Hospice: YES□NO□
Urgency of referral (circle)ASAP2-4 daysplanned date
PATIENT DETAILS
Name: …………………………………………………………Gender: ………...... DOB:
Home Address including Postcode: ……………………………………...………………………………………………..
………………………………………………………………………………………………………………………………..
NHS Number………………………………………………Tel No: ………………………………………......
Diagnosis……………………………………………………………………………………………………………………..
Does Patient have Preferred Priorities of Care (PPC) in place YES□NO□
Patients Current Location (if different from home address) ……………………………………………………………...
Carer: ...... Tel. No: ......
Hasthe Carer been Informed of this Referral : YES□NO□
Background Information (treatment/investigations/past medical history/recent events/social issues)…………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………......
Infection Status: Does the patient currently have or have a history of a notifiable infection (please tick)
MRSA □ Clostridium Difficile □ Other (please state) ……………… Date of infection ……………………………..
GP:…………………………….Tel No:…………………Is GP aware of Referral:YES□NO□
PROFESSIONALS INVOLVED
D/N: ……………………………………………………...... Mobile No:………………………………………………......
Macmillan Nurse: ...... Mobile No: ......
Social Worker:……………………………………………Mobile No: ……………………………………………………
Consultants: ………………………………………………………………………………………………......
CURRENT CONCERNS
………………………………………………………………………………………………………………………......
………………………………………………………………………………………………………………………......
………………………………………………………………………………………………………………………......
………………………………………………………………………………………………………………………......
……………………………………………………………………………………………………………......
REASON FOR REFERRAL
Inpatient Unit / Please Tick / Outpatient Services / Please TickSymptom Control / Outpatient Appointment
End of Life Care / Domiciliary Visit
Rehabilitation / Lymphoedema Clinic
Psychological Support / Spiritual Care
Other (please specify) / Day Hospice (Wednesday)
Social Support
Alice House Care Agency:
Respite / Day Service / Complementary Therapy / Sitting Service. / Contact
01429 855553
CURRENT MEDICATIONS
Drug / Dosage / Drug / Dosage1 / 6
2 / 7
3 / 8
4 / 9
5 / 10
FOR HOSPICE USE ONLY:
Date & Time of Receipt of Referral: …………………………………………………………………………..
Received & Reviewed by: (print name) ………………………………………………………………………..
DISCUSSION WITH REFERER WITHIN 2 HOURS OF RECEIPT OF REFERRAL
Referrer Informed of Decision:Date…………………Time………………………………………………...
Contact Assessment Attached: Yes □ No □
Referral:Accepted□Declined□
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