IF YOU ARE A TPP SYSTMONE USER YOU CAN REFER PATIENTS ELECTRONICALLY DIRECTLY THROUGH SYSTMONE. Please see for more information on setting this up.

Surname: / First names:
Title / SelectMrMrsMissMsDrOther (please specify) / Marital Status / SelectMarriedCohabitingSeparatedDivorcedSingleWidowedUnknownOther (please specify)
DOB: / Sex: / SelectMaleFemaleIndeterminateUnspecifiedUnknown
Address: / Occupation Status: / SelectEmployedSelf-employedUnemployedRetiredStudentHousepersonUnknownOther (please specify)
Type of Occupation:
Patient Lives Alone / YesNo
Post Code / Ethnic Group: / SelectWhite BritishIrishWhite otherWhite & Black CaribbeanWhite & Black AfricanWhite & AsianMixed otherIndianPakistaniBangladeshiAsian otherCaribbeanAfricanBlack otherChineseArabOther ethnic groupNot stated
Telephone Home:
Mobile: / SelectNoneUnknown
SelectNoneUnknown / Religion:
NHS No: / Hospital No:
UnregisteredUnknown
Main CarerSelectSee belowNoneUnknown / Next of Kin (if different)
Name: / Name:
Address: / Address:
Post Code: / Post Code:
Telephone: / Telephone:
Relationship: / SelectHusbandWifeSonDaughterPartnerParentOther (specify) / Relationship: / SelectN/AHusbandWifeSonDaughterPartnerParentOther (specify)
Are they the NOK Yes
No / Names & ages of any under 18s in the family network / Name / 0
(further names & ages can be added at the end of the referral form) / Name / 0
Heath & Social Care Practitioners
Date of Referral(dd/mm/yyyy) / Location of Patient/ Client on Referral / SelectHomeCommunity HospitalRUHNursing HomeResidential HomeOther
Referred by / Base
Position / Telephone
GP / Hospitals involved
Practice / Consultants
District Nurse / Social Worker
Key Worker / Allied Health Care Professional
Primary Diagnosis / Date of Diagnosis (dd/mm/yyyy)
Site/s of Metastases / None / Unknown
Other Significant Diagnoses?
Known Allergies?
Does the patient have:
/ A life threatening condition / SelectYesNoUnknown
Complex physical, psychosocial, or spiritual needs
/ SelectYesNoUnknown
Does the patient have any communication needs that we need to be aware of?
NoYesPlease give details:
Do the relatives or carers of the patient have related complex needs themselves which require additional specialist support? (Preferably with the knowledge of the patient)
/ SelectYesNoUnknown
Referral for Dorothy House Hospice Services
Specific reason(s) for referral / Further details
Early Referral Clinic
Symptom Control
Emotional/Psychological Support
Spiritual Support
Rehabilitation/Readaptation
Support for Carer
Advice re Future Management
Management of Lymphoedema
Terminal Care
Inpatient Unit Admission - for acute admission only,please call 01225 722999 for further discussion, and complete form
Hospice at Home (Please complete form and call 01225 722 921 for further discussion)
Contact Priority
/
Urgent (1-2 days)
Soon (within 1 week)
Routine (within 2 weeks)
/
Is the patient on the End of Life Care Register?
/
SelectYesNoUnknown
Is the patient/client aware of this referral /
SelectYesUnawareUnknown
Is the GP aware of this referral /
SelectYesNoUnkown
Could the patient/client travel as an outpatient? SelectYesNoUnknown
Are there any risks to lone workers? /
SelectYesNoUnknown Comments:
Has the patient consented to share medical information with relevant healthcare professionals?
/

SelectGivenRefusedNot asked for yet

(for further information on the principles of obtaining patient consent see

Further referral information attached:
Copy Letters Results of Investigations List of medication Other
Any other comments:
Date (dd/mm/yyyy): Person completing form: