Community Urban Palliative Care Consult Form
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1
2Palliative Care Consult Service – Community (Urban)
Phone 403.944.2304
Fax 403.270.9652
Consult Service Request
Date
Please fax the completed form to 403.270.9652
(yyyy-Mon-dd)
Patient Name
PHN#
Date of Birth
PARIS ID#
(yyyy-Mon-dd)
Address
Postal Code
Phone
Diagnosis
Primary: Cancer
Metastases
Primary: Non-Cancer
Co-Morbidities
Reason for Consult
Consult Only
Assess for Possible Transfer of Care
New Diagnosis
Pain Management
Symptom Management
Deteriorating physical or cognitive function
Psychosocial distress for person or family
Spiritual distress for person or family
Education needs of the person or family
End of Life decision making
Coordination of care
Transition to Hospice
Please describe the concern(s) that has/have promoted this referral.
Is patient aware of referral?
Yes
No
Type of Residence
Live with
PAL
No one (alone)
Personal Care Home
Spouse
Private Home
Family
Lodge
Other (i.e. non-relatives)
____________________
Other
___________________________________
__________________________________________
The referring source will be contacted within 3 - 5 business days upon receipt of the referral.
If consult requests are emergent (same day), the patient’s physician can obtain immediate phone
advice from a Palliative Care Physician Consultant by contacting RAAPID at 403-944-4486
Consult Requested by
(please print)
OT
PT
RRT
RN
MD
SW
Team
Pager
Cell
Primary Care Physician
(please print)
Contact Number
Physician Informed of Referral
Yes
No
Home Care Coordinator
(please print – if different than above)
Phone
Pager/Cell
Team
For Offi ce Use Only – Notifi cation of Team
To
Date
(please print)
(yyyy-Mon-dd)
By
Via
Pager
Email
Phone
(please print)
Fax
Voice Mail
Other
______
101791Rev2016-02)
Page 1 Side A
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