Download Referral Form - G-Care

Referral Form version 1.3 Apr 2016
Please complete and return via Email [email protected] or Fax 0300 421 6814
Patient full name:
Patient details:
D.O.B:
Or
NHS Number:
Preferred phone number:
House name/number:
Patients GP.
Dr
Name of GP Practice.
Email:
Post Code:
Date of Referral:
Please indicate if below documents have been
completed
Holistic Needs Assessment Completed
Y/N
Reason for Referral: Please give details:
Physical:
Cancer Care Plan Completed
Y/N
Functional:
Cancer Care Review Completed by GP
Y/N
Social:
Psychological:
Please indicate primary cancer diagnosis and cancer treatment to date
Surgery
Chemotherapy
Radiotherapy
Breast
Cancer
Prostate
Cancer
Colorectal
Cancer
Date of primary diagnosis
Current Treatment Status
Pre treatment
As at 05.04.2016
During treatment
Hormone
Other-please state
Disease stage at diagnosis
Post treatment
Ongoing -Advanced Metastatic
Previous Medical History
Current Medication:
Any other long term conditions:
Allergies:
Referrers Details: [Only complete if different from patients GP]
Referrers name:
Referrer role:
Referrers direct Tel Number:
Referrers email:
Referral completed with patient: Yes / No
How did you hear about Macmillan Next Steps?
If you would like to speak with a member of the Macmillan Next Steps Team to discuss your referral, or services
available please call:
: 0300 421 6586
Once you’ve completed your referral please fax or email to Macmillan Next Steps
Fax: 0300 421 6814 or : [email protected]
As at 05.04.2016