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.
* Required
PATIENT NAME
*
Your answer
PATIENT AGE
*
Your answer
PATIENT CONTACT NUMBER
*
Your answer
PATIENT ADDRESS
*
Your answer
REFERRAL PHYSICIAN NAME
*
Your answer
REFERRAL SOURCE
*
ODCH
PCMH
Connaught Hospital
China-SL Friendship Hospital
34 Military Hospital
Personal (not referred by doctor or nurse)
Other:
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.
Pain
Dyspnoea/breathlessness
Goals of Care Discussion
Psychosocial/Spiritual Issues
Nausea/vomiting
End of Life Care
Other:
Required
What is the Diagnosis?
*
HIV
Active TB
Cancer
Organ Failure/End-stage organ disease
Patient has more than one of the above diagnoses
Other:
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