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The Malta Hospice Movement
39 Good Shepherd Avenue - Balzan BZN1623
Tel: 21 44 00 85 Fax: 21 48 47 69
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REFERRAL FORM
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Malta Hospice Movement offers Palliative Care to the patient and support to the family
and works together with existing Health & Social Services. |
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Name of Patient ________________________________ I.D. No. ___________________
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Date of Birth _______________ Tel.No. ________________ Religion ________________
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Address _________________________________________________________________
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Diagnosis ________________________________________________________________
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Is the patient aware of Diagnosis? Yes _____ No ______ Don"t know _________
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Reason for referral _________________________________________________________
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________________________________________________________________________
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Present Problems _________________________________________________________
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Present location of Patient __________________________________________________
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* I, the Patient, hereby give my consent to The Malta Hospice Movement to process
and record personal data, including data controlled by MDH in order to be provided full care as needed. |
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Patient’s Signature ______________________________
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* I, the Doctor, hereby confirm that it is not in the Patient’s best interest to know
he/she is receiving Hospice Care. |
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Doctor’s Signature ______________________________
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Family Doctor _________________Tel. No._______________ Mob. No. ____________
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Consultant _______________________________________________________________
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Referring Doctor ________________ Tel. No. _____________ Mob No. ______________
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Date ___________________ Referring Doctor’s Signature _________________________
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Next of Kin ____________________I.D. No _______________ Relation ______________
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Address __________________________________________________________________
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Telephone Number ______________________ Mobile ___________________________
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* I, next of kin, hereby give my consent to The Malta Hospice Movement to process
and record my personal data, including data controlled by MDH. I am fully aware
that I can access my data at any time should I wish. |
| Next of Kin Signature ____________________________ |
| * In compliance with the Data Protection Act XXVI of 2001 |
