Patient Medical Referral

Helderberg Hospice – Medical Request For Referral

This form is for the Medical Practitioner to complete. We require ALL of the information in order to fully assess the patient’s suitability for Hospice Services. Please note that, as a Non-Profit Organisation, our service capacity is sometimes limited and, it may not always be possible to accept all patients onto service immediately and, where appropriate, the admission may be deferred for a period of time or referred to an alternate institution for further suitable care or support. Once we receive your completed medical referral request form, we promise to get back to you within 48 working hours to advise you of the status of your referral. Should the information provided be insufficient for us to make a determination around suitability for service, we will request further information from the patient, the patient’s family or the patient’s care team. In these instances, it may take a further 48 working hours to finalise an admission. In any event, you can expect a referral for admission to take between 2 to 4 working days. Please note that we do not process referrals for admissions, of new patients, on weekends or public holidays.

Other Form To Complete: PATIENT PERSONAL INFORMATION