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Oakhaven

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Referral form

If you’d like to refer a patient to Oakhaven please either  complete this Word document Oakhaven Hospice Referral Form or use the online form below:

 

Specialist Palliative Care Referral Form

For use by healthcare professionals wishing to refer a patient

Step 1 of 3

33%
  • Essential referral details

     This referral will NOT be processed without the valid consent of the patient or their proxy.

     Please ensure patients are aware information will be held on computer according to the Data Protection Act.

     Please attach ALL recent relevant clinic letters and investigations

     Inadequate supporting information may result in the referral being declined.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • e.g. which hospital/ward or home
  • GP Details:

  • (All RAPID referrals must also be referred to the District Nursing Team)
  • (All RAPID referrals must also be referred to the District Nursing Team)
  • (primary diagnosis/metastases/complications – including relevant treatment)
  • Please summarize current problems and specific aims of referral to Specialist Palliative Care Team:
  • Additional Information:

  • e.g. RIG/PEG feeding, NIV, oxygen (if on oxygen specify L/min):
  • (patient or family/carer)
  • e.g. home environment, patient, family, pets, smoky environment:
  • Advance Care Planning:

  • Document Upload:

  • Drop files here or
    Max. file size: 128 MB.
    • Drop files here or
      Max. file size: 128 MB.
      • Drop files here or
        Max. file size: 128 MB.
        • Drop files here or
          Max. file size: 128 MB.

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          t: 01590 613025 (9am-5pm admin office)
          01590 670346 (24hr patient enquiries)
          e: info@oakhavenhospice.co.uk

          Oakhaven Hospice
          Lower Pennington Lane
          Lymington
          Hampshire, SO41 8ZZ

          Celebrating 30 years 1992 - 2022         member of hospice uk

           

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