Get in touch 01527 871051
Patient self-referral form
Primrose Hospice is happy to accept self-referrals to our Clinical services.
These referrals can be made by an individual, a family member or by a patient’s GP.
After your patient referral form has been received, a member of the Clinical team will review it and call to discuss different care options available at Primrose.
To talk to someone at Primrose Hospice, please call during office hours on 01527 871051.
If you would like to speak to someone about being referred to our Family Support services including bereavement support, please call 01527 889799.
Patient's date of birth
Patient's NHS number (if known)
Patient's address and postcode
Patient's telephone number
Patient communication needs?
Can patient be seen as an Outpatient or in a Day Hospice setting?
If no, what is the indication to see them at home?
Who should we contact?
Has the patient given you consent to refer them to Primrose Hospice?
Contact's name (optional)
Contact's address (optional)
Contact's telephone number (optional)
Can we leave a message? YesNo
Can we disclose where we are calling from? YesNo
Is GP aware of referral?
Do we have consent to contact your GP?
Would you be able to travel to Primrose Hospice?
Reason for referral
If you are a clinician and are able to provide additional information, please email email@example.com
Work with GPs
The Primrose Unit
Key Nurse Role