Refer to THE SHEPHERD'S HOSPICE, Macdonald Village
Please fill in this form to refer your patient to our Palliative Care Multidisciplinary Team. (It should take about 5 minutes)

For enquiries please email referTSH@gmail.com or call us: 079076906 or 080306748

We will revert to you within 1 working day.

PATIENT NAME *
Your answer
PATIENT AGE *
Your answer
PATIENT CONTACT NUMBER *
Your answer
PATIENT ADDRESS *
Your answer
REFERRAL PHYSICIAN NAME *
Your answer
REFERRAL SOURCE *
REFERRAL PHYSICIAN CONTACT NUMBER OR EMAIL *
Your answer
REASON FOR REFERRAL *
Please help us by also providing RELEVANT CLINICAL DETAILS in the free text section "Others" e.g. LOCATION, CAUSE, SEVERITY of pain, elaborate on patient's clinical condition if referring for end of life care, or summarise communication to date if referring for goals of care discussion.
Required
What is the Diagnosis? *
What are the Diagnoses?
Please select all that apply.
*
Required
Which of the diagnoses is the main problem (most likely cause of death)? *
Please tell us more about the cancer.
Which organ/site? *
Required
Any secondary metastases to other organs? Please state any radiological findings, specific location, or reason for suspecting metastases in "Other". *
Required
Please tell us more about the end-organ illness.
If your patient has an end-organ disease:
Which organ(s)? *
Required
What is the cause or underlying illness?
Please tell us what has been done so far to treat the illness.
Please be as specific as possible e.g. name of drugs/therapy/surgery/duration/dosage.
What medication or intervention has been done?
Your answer
Lastly, some information for us to plan ahead...
Please state expected Prognosis
Does patient know that he/she is referred for palliative care? *
Referring for Which Service? *
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