Specialist Palliative and Supportive Care Referral Form	
Referral to:		

	PALLIATIVE CARE INPATIENT UNIT		

	COMMUNITY PALLIATIVE CARE SERVICE	
ATTENTION:		

	Dr Bridget Johnson (Greenwich)		

	Dr Sarah Thompson (Neringah)	

	Dr Phil Macualay (Northern Beaches)	
Patient Name:	<PtFullName>	Medicare No:	<PtMCNo>	
Address:	<PtAddress>	Health Fund Name:	<PtInsFund>	
	,  	Membership No.:	<PtInsNo>	
Phone:	<PtPhoneH>	Language:		
DOB:	<PtDoB>	Lives alone?		

	Yes		

	No	
Gender:	<PtSex>	Interpreter Needed?		

	Yes		

	No	
Referring GP:	<DrName>	Reason for referral (can select more than one):	
Practice Name:	<Practice>			

	Symptom Control		

	Terminal Care	
Phone:	<UsrPhone>			

	Psychosocial Support		

	Supportive Care	
Consent to referral?		

	Patient		

	Family		Patient and family concerns:		
Person Responsible:		Understanding of disease:		
Relationship:		Goals of care:		
Phone:		Spiritual / cultural needs:		
Palliative care consultant:			
Diagnosis and Treatment:	Medical History:	
		
NSW Health Resuscitation Plan completed?		

	Yes (please attach)		

	No		
Infection status and location:			
Special instructions (tracheostomy, wound care, CVADs, PEG, modified diet needs):	Falls risk / behavioural concerns:	
		
Functional status:		

	Independent		

	Partial assist		

	Full assist	Aids:		
Skin integrity:		Waterlow score:		
Referring GP/specialist
Signature: 

Provider No.: <DrProviderNo>
Date:  <TodaysDate>	PLEASE FAX COMPLETED REFERRAL TO:	
(Just Add Information)	

Greenwich Hospital	
Inpatient Unit	
Fx: 9903 8100	
Ph: 9903 8227	

	

Neringah Hospital	
Inpatient Unit	
Fx: 9487 1599	
Ph: 9488 2200	

	

Palliative Care Community North	
	
Fx: 9903 8265	
Ph: 1800 427 255	

(For urgent referrals please phone the relevant number above)