ࡱ> X[W bjbj44 DJVV.L|hh&&&8^<&+.Ndzzz*******$6-/*M "M M *zz<*###M ^8zz*#M *###z0Ğo! 4#s**0+#0 0#0#p>,#B$f**!+M M M M 0h :  Horton General Hospital Palliative Care Support Team Referral Form Please complete side 1 and contact the Palliative Care Team ext-24195 or e-mail:  HYPERLINK "mailto:Hortonpalliativecare@ouh.nhs.uk" Hortonpalliativecare@ouh.nhs.uk  Date of referral: Time: Surname:Title:Gender:Lives alone: Yes / No First Name:D.O.B: Age:Address: Post Code:NHS No:Hospital No:Telephone:KHH No:Next of Kin / Main Carer detailsName: Contact details:Relationship: Any existing Care Agency Information:Known to PCS? Yes/NoGP: District Nurse: Key worker:Address:Telephone:Current location of patient: HGH Consultant: Main diagnosis & date:: Agrees to referral: Consultant / Patient Medical history: Details of admission: Reason for referral (please give details of uncontrolled symptoms, psycho-social issues, needs of family / carers etc) Referred by:Name: Title:Contact details: Signature:Date:Time:FOR OFFICE USE ONLYTelephone calls/advice given Signature.. 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