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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
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