Referral form - Wigan & Leigh Hospice

Referrer*

Email address*

Telephone number*

Service Required

Community Hospice Nurse Specialist (Outpatient clinic/ Domiciliary visits)
Hospice in your Home (Patient must be known to District Nursing service. If urgent response needed please fax referral & leave message for Hospice in Your Home Co-ordinator on 07551 153266.)
Hospice in Your Care Home (Referrals from Care Home staff only)
Oak Centre
Medical Outpatient Clinic
Inpatient Unit Admission

Have you already discussed this patient with hospice staff?*

Yes
No

If Yes, who have you spoken to?*

Patient Details

Surname*

Forename*

Date of birth*

Home/Care Home Address*

Street Address Address Line 2 City County Postcode

Telephone number*

NHS Number

Ethnic group

Does patient live alone?*

Yes
No

Next of kin*

Relationship to Patient*

Next of kin address*

Street Address Address Line 2 City County Postcode

Next of kin telephone number*

Patient's current location*

Home
Hospital
Care Home
Other location

Access/Safety issues*

Name of hospital & ward*

Give details*

GP

Is GP aware of referral

Yes
No

GP's Address

Street Address Address Line 2 City County Postcode

Telephone number*

Consultant(s)

Hospital(s)

Clinical details

Diagnosis & extent of disease*

Estimated prognosis

Important events and treatments*

Other related conditions

Any barriers to communication

Any specific nursing needs

Medication

Does patient have an Advance Care Plan or any preferences for their future care?*

Yes
No

If yes, give details*

Is patient on GSF Register*

Yes
No
N/A

Is Individual Plan of Care for the dying person in use?*

Yes
No
N/A

Is a DOLS in place?*

Yes
No
N/A

Reason for referral - Please tick relevant problem(s) & give details*

Paint/Symptom control
Emotional/Psychological support
Advance care planning
Carer support
Other reason

Details*

Patient consented to referral?*

Yes
No
Best Interests Decision

Patient aware of diagnosis/prognosis*

Yes
No

Family aware of referral*

Yes
No

Family aware of diagnosis/prognosis*

Yes
No

If no to any of the above, please state the reason why*

Other agencies involved

Social worker Name

Social worker telephone number

District nurse Name

District nurse telephone number

Disease-specific CNS Name

Disease-specific CNS telephone number

Other Professionals Name

Other professionals telephone number

Consent

I agree to the privacy policy.