Date of issue : 23 March 2012

WIRRAL SPECIALIST PALLIATIVE CARE REFERRAL FORM

Please complete all sections accurately and fax

COMMUNITY INTEGRATED SPC TEAM TEL : 0151 328 0481 FAX : 0151 328 0482
WIRRAL HOSPICE ST JOHN’S TEL : 0151 482 8989 FAX : 0151 343 9589
Please indicate which service In Patient Out Patient Day Care
WIRRALHOSPITAL SPC TEAM TEL : 0151 604 7433 FAX : 0151 604 7085
URGENT REFERRAL  / ROUTINE REFERRAL  / DATE OF REFERRAL
CURRENT PATIENT LOCATION
If Inpatient please give ward & Extn. / Home/Inpatient / PLANNED DISCHARGE DATE
Eligible for DS1500 YES/NO
Ward / Extn. / In receipt of DS1500 YES/NO
PATIENT DETAILS

Surname

/

Forenames

Marital Status / Single/Married/Divorced/Sep/Widowed / Sex / Male Female
DOB

Address

Post code

Tel No (home) /

Tel No (work)

NHS No / Hospital No
RESPONSIBLE RELATIVE/MAIN CARER DETAILS

Surname

/

Forenames

Relationship
/
Tel No.
Address
PRIMARY HEALTH CARE TEAM

GP Name

/ Tel No.
GP Address / Fax No.
Comm. Macmillan Nurse / Hospital Macmillan Nurse
District Nurse / Tel No.

DIAGNOSIS

Issued by Cancer Guidelines Implementation Group & Wirral Hospital NHS Trustref: Palliative Care Referral Form

Date of issue : 23 March 2012

Primary Site (s) / Date of Diagnosis

Issued by Cancer Guidelines Implementation Group & Wirral Hospital NHS Trustref: Palliative Care Referral Form

Date of issue : 23 March 2012

Secondary Site (s) & date of diagnosis / Liver 
Date / Lung 
Date / Bone 
Date / Cerebral 
Date / Other 
Date
Disease status / Recent diagnosis  Re-occurrence  Late stage diagnosis  Uncertain 
Patient/Carer awareness of diagnosis/prognosis
Patient / Disease Y/N* Prognosis Y/N* Referral Y/N*
Kin/Carer / Disease Y/N* Prognosis Y/N* Referral Y/N* (Delete as necessary)

REASON FOR REFERRAL

Complex Symptom Management  Complex Psychosocial Support 
Specific Current Problems :
NAME : / DOB :
FURTHER CLINICAL INFORMATION AND TREATMENT INCLUDING MEDICATIONS
Surgery :-
Type
/ Date / Surgeon
Radiotherapy :-
Site(s) / Date(s) / Consultant
Chemotherapy :-
Date(s) & No. of cycles / Palliative/Curative / Consultant
Clinical Oncologist / Medical Oncologist
Medication / Dosage / Frequency / Medication / Dosage / Frequency
SIGNIFICANT PAST MEDICAL HISTORY
SOCIAL HISTORY/BACKGROUND :-
Religion / Ethnicity / Occupation
Mobility : Independent  Independent with walking aid  Wheelchair 
Lives : Alone  Not Alone 
Type of accommodation : House  Bungalow  Flat  Nursing home  Other ______
Other services involved ?

Please tick perceived level of intervention

  1. Telephone advice to Professional/Patient/Carer 
  2. Single visit to deal with specific problem (i.e.Pain/Symptom management 
  3. Short intervention to deal with specific problem ( i.e. difficult pain/symptom/emotional needs) 
  4. Multiple complex problems requiring frequent re-assessment. 

Hospice referrals must be signed by a doctor.

Referrers Signature ………………………………………….. Please print name and give extn. In case ofquery

Name : …………………………………………………………… Extn. …………………

Status – GP/Consultant/Other* Delete as necessary

(Training Grade(Please give name of referring consultant &Contact Number).

Name of referring Consultant……………………………………. Contact No. ……………………

Issued by Cancer Guidelines Implementation Group & Wirral Hospital NHS Trustref: Palliative Care Referral Form