Palliative Care Consult Referral Palliative Care Consult Referral Form Step 1 of 3 33% Health Care Provider (HCP) Making ReferralName of Person Referring * Required First Last Preferred Date to Contact - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY Preferred Time to Contact * Required : HH MM AM/PM AM PM Job Title * RequiredOrganization Name * RequiredCity/Area * RequiredBramptonBurlingtonCaledonDufferinHalton HillsMaltonMiltonEast MississaugaWest MississaugaOakvillePhone Number and Extension * RequiredEmail * Required Alternate Contact Information at HCP First Last Job TitlePhone Number and ExtensionEmail Patient/Resident InformationPatient/Resident Name * Required First Last Date of Birth - must be dd/mm/yyyy format * Required Date Format: DD slash MM slash YYYY Age * RequiredIn your opinion, would you be surprised if the patient/resident dies in the next 12 months? * RequiredYesNoIs the patient/resident receiving a palliative approach to care? * RequiredYesNoPalliative Performance Scale (PPS) * Required100%90%80%70%60%50%40%30%20%10%Diagnose(s) * RequiredAllergies * RequiredName of Most Responsible Physician (MRP) and/or NP Involved * RequiredRelevant Medications for Symptom Control (Click + to add additional line)MedicationDosageRouteTimes Given Optional: Upload a Medical Administration Record (MRP) or Medication List SBAR Communication ToolSITUATION: The complex problem/symptom is: * RequiredBACKGROUND: State the Pertinent medical history/any recent trauma: * RequiredGive a brief synopsis of the treatment to date and effectiveness: * RequiredASSESSMENT: * RequiredCognitively IntactCognitively ImpairedO: OnsetP: Precipitating & Alleviating FactorsQ: Quality of PainR: Region & RadiationS: SeverityT: Timing/Treatment (Current medications for symptoms)U: "How is the pain affecting you?"V: Values - What is the acceptable level for this symptom?Assessment Tool Used:PainADAbbeyPACSLACNone of the AboveOther Assessment Tool Used:Results/Findings of AssessmentIs DOS being utilized? * RequiredYesNoRECOMMENDATIONS: What would your suggestions be?Results of relevant lab tests and imaging (X-Rays, CT, MRI, etc.) & please include dates completedAny other thoughts/concerns?ConsentAcclaim Health is committed to individual privacy and has taken reasonable precautions to ensure the security of the information you are submitting through this online form. By clicking "I agree" you are acknowledging and accepting the potential risks inherent in submitting personal information and/or personal health information online. Please contact us by telephone at 905-827-8111 if you do not wish to submit this information online and we will be happy to assist you. I agreeCAPTCHA