Self-Referral Adult Service Form - Dougie Mac Referrals

Please fill in the form below to start the referral process.

Data Collection Information: The data you provide on this form will be used by Douglas Macmillan Hospice to add you to our clinical database, giving us access to your medical records. For more information, please refer to our privacy notice.

Consent

1. Has the individual consented to this referral? (if over 18 years of age)*

For more information about what we mean by consent in this context click here and visit the FAQ section.

Please ask the individual for their consent before completing this referral.

Please provide more details*

Individual Information

1. Has the individual been previously known to Dougie Mac?*

Yes

No

If you are over 18, and it is within the last 6 months you can stop this referral and call our Advice Line on 01782 344300 because you do not require a new referral.

2. Full Name*

3. Preferred Name

4. Gender*

5. Date of Birth*

6. Address

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

7. Telephone Number*

8. Language*

9. Does the individual have any communication difficulties?*

Yes

No

What is the preferred method of communication/contact?*

10. NHS Number*

To find your NHS number visit here.

11. Please tick the option that best describes you*

Your Name*

Your Telephone Number*

Your relationship to the person being referred*

Please state:*

How can we help?

1. Please describe your/their condition in your own words and why you/they would benefit from our support

2. Are you/they receiving support from any other services in relation to your/their health needs?

Contact

Adult Self-Referral

Please ask the individual for their consent before completing this referral.