REFERRAL FORM FOR SPECIALIST PALLIATIVE CARE SERVICES	
	REFERRAL FORM FOR SPECIALIST PALLIATIVE CARE SERVICES	
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Referral To	
o	Mercy Palliative Care Sunshine
Community Palliative Care 
3 Devonshire Road
Sunshine, VIC 3020
1300 369 019 (phone)
03 9364 9198 (fax BH)
03 8754 3741 (fax AH)	o	Werribee Mercy Hospital
Inpatient Gabrielle Jennings Centre
300 Princes Highway
Werribee, VIC 3030
03 8754 3731 (phone)
03 8754 3735 (fax)	o	
Non-malignant SMART Outpatients Clinic
Werribee Mercy Hospital
300 Princes Highway
Werribee, VIC 3030
03 8754 6710 (fax)	

Provider No:	
<<Doctor:Provider Number>>	

Signature:	

	
Referrer Details	Patient Details				
Name	Treating Doctor.Name Treating Doctor.Name 	Surname:	Patient Demographics.Surname 		
Clinic:	Practice.Name 	Given Name(s):	Patient Demographics.First Name 		
Address:	Treating Doctor.Address , Treating Doctor.Suburb Treating Doctor.Postcode 	Address:	Patient Demographics.Address , Patient Demographics.Suburb Patient Demographics.Postcode 		
Phone:	Treating Doctor.Phone 	Phone:	Patient Demographics.Phone (Home) 		
Fax:	Treating Doctor.Fax 	Mobile:	Patient Demographics.Phone (Mobile) 		
Email:	Treating Doctor.E-mail 	Email:	Patient Demographics.E-mail 		
Relationship:		Gender:	Patient Demographics.Gender 		
Primary Carer / NOK	Date of Birth:	Patient Demographics.DOB 			
Surname:		Country of Birth:	Country of Birth 		
First Name:		Indigenous:	o No o Aboriginal o TS Islander		
Address:		Preferred Language:	Preferred Language 		
Phone:		Interpreter Needed:	o Yes o No		
Mobile:		Diagnosis: 	o Malignant o Non-Malignant		
Email:		General Practitioner			
Relationship:		Name:			
Secondary Carer / NOK	Clinic:				
Surname:		Address:			
First Name:		Phone:			
Address:		Fax:			
Phone:		Email:			
Mobile:		Medicare / Insurance			
Email:		Medicare No:	Patient Demographics.Medicare Number 		
Relationship:		PH Insurance:	o Yes o No		
Other Carer / Case Manager	PHI Provider:	Patient Demographics.Health Fund Name 			
Surname:		PHI Card Number:			
First Name:		DVA:	Patient Demographics.DVA Number 		
Address:		DVA Card Number:	o No o Gold o White		
Phone:		Other Information			
Mobile:					
Email:					
Relationship:					
Client Name:	Patient Demographics.Full Name 	DOB:	Patient Demographics.DOB 	UR/MRN:		
Service requested:	o IPPC o IPPC Back Up Bed o Community Palliative Care o Outpatient Clinic 					
Reason for Referral:	o Symptom Management o EOLC ☐Other:					
Priority:	o Urgent (within 2 days) o Semi-urgent (can wait 1 week) o Non-urgent					
Diagnosis / Recent History / Planned Treatments						
						
Past Medical History						
						
Clinical Information Supporting Referral for Service						
Phase of Care:	o Stable o Unstable o Deteriorating o Terminal					
Physical Symptom	Additional Information					
o Pain						
o Dyspnoea						
o Nausea						
o Vomiting						
o Bowel						
o Tiredness						
o Appetite						
o Other						
Psychological Symptom Issues:	o Anxiety o Depression o Confusion o Restlessness o Existential Distress o Other					
Family / Caregiver Issues:	o Anxiety o Distress o Exhaustion o Unable to meet care needs o No carer o Complex Need	

o Lives alone o Lives with family/other 	

o Significant health issues:	

					
Current interventions:	o Oxygen o Syringe Driver o IDC o Ext. Drains o PPM/AICD o Wound	

o Other:	

					
TO ACTION THIS REFERRAL THE FOLLOWING IS MANDATORY						
o DISCHARGE SUMMARY
o PATHOLOGY & RADIOLOGY REPORTS
o EQUIPMENT PROVIDED	o OTHER RELEVANT CLINICAL INFORMATION
o ANTICIPATORY MEDICATION ORDERS
o SERVICES ARRANGED OR IN PLACE	ADDITIONAL INFORMATION CAN BE ATTACHED				
MERCY HEALTH USE ONLY Referral Accepted:	o YES o NO