Call our 24/7 advice line for health care professionals and families if you need support with symptom management and end of life care - 01284 766133.

Referral form – Sylvan Ward

What we do

Manage symptoms that are complex and have been difficult to control at home
Help people adapt to changes so that they can go back home
Provide care at the end of life when it is not possible to die at home

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Date
DD slash MM slash YYYY
Reason for referral(Required)
- Symptom management for uncontrolled or complicated symptoms that have not responded to initial treatment(s)
- Social Crisis – please note we can offer short stays (usually around 7 days) to support carer breakdown, and we may set a discharge date on arrival
- Patient’s preferred place to die
Please note Sylvan Inpatient Ward is a short stay unit.
Please complete this form to the best of your ability; incomplete or inaccurate forms will result in a delay in admission.
Please note that inpatient requests are discussed at 0930 each morning, they are allocated on clinical need and not length of time on the waiting list.
Please be aware that if a patient declines a bed they will be removed from the bed waiting list.
Please discourage patients from bringing in unlabeled, or unprescribed medications.
Is the patient known to St Nicholas Hospice Care(Required)
- Yes
- No
Please stop form and call Clinical admin on 01284 702525 in hours or 01284 766133 out of hours to discuss with a triage nurse.
Referrer details
Name(Required)
First Last
Job title
Telephone number(Required)
Email(Required)
Enter Email Please confirm Email
Patient details
NHS number(Required)
If unknown, please insert 0000000000
Name(Required)
First Last
Date of birth(Required)
DD slash MM slash YYYY
Address(Required)
House name/number and street Address Line 2 Town County Post Code Country
Telephone number(Required)
GP practice(Required)
If other, please state:
Please contact the GP to find out where the patient's local hospice is.
Contact St Nicholas Hospice Care's Clinical Admin team on *** if there is a specific reason you still wish referral to be considered, e.g. moving in with a relative and changing GPs.

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Referral form – Sylvan Ward

What we do

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Your Experience survey

Referral form – Sylvan Ward

What we do

Step 1 of 4

Referrer details

Patient details

Next of kin details

Medical details

Protecting your data

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Want to hear more from St Nic's?