Refer to THE SHEPHERD'S HOSPICE, Macdonald Village

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Please fill in this form to refer your patient to our Palliative Care Multidisciplinary Team. (It should take about 5 minutes)

For enquiries please visit or call us: 079076906 or 080306748

We will revert to you within 1 working day.

PATIENT NAME *

PATIENT AGE *

PATIENT CONTACT NUMBER *

PATIENT ADDRESS *

REFERRAL PHYSICIAN NAME *

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 *

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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