Patient's Name

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?
YesNo

If no, what is the indication to see them at home?

Who should we contact?
PatientSomeone else

Has the patient given you consent to refer them to Primrose Hospice?
YesNo

Contact's name (optional)

Relationship (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?
YesNo

Do we have consent to contact your GP?
YesNo

GP's Name

GP's practice

Main diagnosis

Would you be able to travel to Primrose Hospice?
YesNo

Reason for referral