Patient self-referral form
We support people living with life-limiting illness across Bromsgrove, Redditch and surrounding areas.
Before you begin:
The form takes around 5–10 minutes to complete. You will be asked to provide some basic personal and medical information so we can understand your needs and offer the most appropriate support.
If you’re unsure about anything, please call us on 01527 871051 and we’ll be happy to help.
Who can complete this form?
– Patients referring themselves
– Family members or carers
– GPs, nurses, or healthcare professionals
We accept both self-referrals and professional referrals.
If you are referring a patient on their behalf, please ensure consent has been obtained from the patient.
What information will I need?
To complete this referral, it helps to have:
– Patient’s contact details
– GP details
– Basic medical information or diagnosis (if known)
– Details about the support needed
If you don’t have all the information, you can still submit the form and our team will contact you.
You can use the links below to find out more about our clinical support:
Day Hospice | Clinic | Physiotherapist | Group Support | Living Well Service
You can download an information leaflet about our clinical services here.
If you would like to speak to someone about being referred to our Family Support services, including bereavement support, please visit this page call 01527 889799.
If you are a clinician and are able to provide additional information, please email this referral form to whcnhs.primrose.hospice@nhs.net
What happens after you submit the form?
– Our Clinical Team will review your referral
– We will contact you within a few days
– We will discuss the most appropriate care and support options
If you have not heard from us within 5 working days, please contact us using the number below.
Prefer to speak to someone?
You can call our team on 01527 871051. (Monday to Friday between 9am-5pm).
We understand this may be a difficult time, and we’re here to guide you.
You can view our frequently asked questions page here.
We would love to hear your thoughts about your experience at Primrose Hospice, so we can improve services.
Please take a few minutes to complete our survey here.
