Referral Form

Diagnoses (including date of diagnosis) (required)

Advance Care Planning has been discussed with the patient

YesNo

An Advance Care Plan has been documented and is held by the patient

YesNo

An Advance Decision to Refuse Treatment (ADRT) is in existence, relevant to the patient’s current care

YesNo

Referral criteria

Share my Care register (in last 5 years of life, no specialist input required)Specialist CNS

Is the patient under the care of any other Consultants (please supply names)

Urgency of referral

URGENT (Maximum 2 working days)STANDARD (Within 5 working days)

If you have classed your referral as urgent, a follow-up call to the team is required. Please call our Mountbatten Coordination Centre on (01983) 533331.