Adult - Referral - Keech Hospice

Please complete about yourself/the person being referred

Title

Name

Firstname Surname

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

GP Details

GP Name / Name of Surgery/Practice(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

GP Email

GP Phone Number

Are you happy for us to contact your GP for additional information to assist with processing your referral?

Yes

No

If no, please be aware additional information will be required from your GP to proceed with your self-referral. In the absence of the authority to contact your GP, we may be unable to proceed with your referral.

In a few short words, please tell us briefly about your (or the person you are submitting this form on behalf of) diagnosis and the reason for your enquiry(Required)

Your details

If you are enquiring on behalf of a family member or friend, please confirm whether yourself of the person being referred should be the main point of contact(Required)

Myself

Person I'm Referring

Title

If you are the main point of contact please complete the details below. Otherwise please submit

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Are you happy for us to contact you by telephone?(Required)

Yes

No

Are you happy for us to leave a message/voicemail?

Yes

No

Are you happy for us to contact you by email?

Yes

No

Thank you for completing your Keech Hospice self-referral. Our team will be in touch within 48 hours to process your enquiry. If your enquiry is urgent or you’d like to speak directly with a member of our care team, please call our Freephone Helpline on 0808 1807 788 or email keech.mcct@nhs.net.

For queries regarding inpatient admissions please contact our My Care Coordination Team 0808 180 7788.

The information provided by yourself and your GP will be held securely and confidentially in accordance with the principles of General Data Protection Regulation 2018. As part of our data protection policy, Keech Hospice will only use your personal data for the purpose of your enquiry and for equality monitoring.

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Refer an adult to Keech

Please complete about yourself/the person being referred

GP Details

Your details