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Clinical Referrals

Pan Birmingham Palliative Care Network Adult Specialist Palliative Care Referral Form

The Pan Birmingham Palliative Care Network has launched a new adult specialist palliative care referral form. This is to be used for all referrals to hospices / specialist palliative care teams in the Pan Birmingham area.

There are 2 versions of this new form. Both forms have the same content:

1. Manual version: This is formatted over 4 sides of A4 to give adequate space for hand written referral information.
2. Electronic version: This is formatted over 2 sides of A4. The sections of the form expand as required when inputting information on the computer. The 2 sided electronic version must not be used for hand written referrals.

Either version can be used but all referrals must be faxed to the appropriate specialist palliative care team as outlined in the accompanying advice notes.

To ensure that all specialist palliative care teams can respond to referrals on an equitable and efficient basis.

Manual Version
Electronic Version
Guidance Notes