SPC Palliative Care Referral Form

Patient information

Note: Questions marked by * are mandatory

Please provide as much information as possible to support this referral for example uploading recent letters, scan reports etc.
Incomplete forms cannot be accepted; we may need to contact the referrer for additional information
All of below:
- Patient has progressive, life limiting diagnosis
- There is complex symptom control, complex functional or psychological issues important to the patient, that cannot be readily managed by the team responsible for care
- The patient agrees to referral to the Community SPC Team, if competent to choose.
If the patient is felt to be in the last four weeks of life, without complex needs, then they will require Hospice @ Home support.
If Hospice @ Home referral is URGENT, please telephone referral TEL: 03000 271 284

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