SHC Common Referral Form

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Step 1 of 4

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Password

Care Type*

Home Care

Inpatient Care

Day Care

Name of Service Provider*

Assisi Hospice

Buddhist Compassion Relief Tzu Chi Foundation (Singapore)

Dover Park Hospice ¹

HCA Hospice Limited

Metta Hospice Care ²

MWS Home Care & Home Hospice

Singapore Cancer Society

St Andrew's Community Hospital ³

Star PALS ⁴

Tsao Foundation

To enquire for more details/service:
¹ Central area (Tan Tock Seng Hospital referrals) only.
² Covers parts of East or North-East Singapore only.
³ Supports non-cancer patients in the East of Singapore only.
⁴ For all referrals to Star PALS, clinicians to complete an additional document attached (PaPaS) for eligibility assessment mandated by MOH.

Is this a ‘terminal’ discharge*

Yes

For referrals to Star PALS only: Click here to complete an additional document before proceeding to fill up the e-form below.

Name of Service Provider*

Assisi Hospice

Dover Park Hospice

Outram Community Hospital

Ren Ci Hospital

Sengkang Community Hospital

St Andrew's Community Hospital

St Joseph's Home

St Luke's Hospital

Name of Service Provider*

Assisi Hospice

Dover Park Hospice ¹

HCA Hospice Limited

To enquire for more details/service:
¹Central area (Tan Tock Seng Hospital referrals) only.

Patient Details

Full Name*

NRIC*

Citizenship*

Gender*

Male

Female

Date of Birth*

DD slash MM slash YYYY

Age*

Race*

Race (Others)*

Language/Dialect Spoken*

You can select more than one.

English

Mandarin

Malay

Tamil

Cantonese

Hokkien

Hainanese

Hakka

Teochew

Others

Language/Dialect Spoken (Others)*

Dialect Group*

You can select more than one.

Cantonese

Hokkien

Hainanese

Hakka

Teochew

Others

Dialect Group (Others)*

Religion*

Religion (Others)*

Marital Status*

Occupation*

Address*

Street Address ZIP / Postal Code Country

Present Location*

Home

Hospital

Contact Number (Primary)*

Contact Type*

Home

Mobile

Office

Contact Number (Secondary)

Contact Type

Home

Mobile

Office

Name of Hospital*

Ward Tel*

Ward/Bed*

Expected date of discharge*

DD slash MM slash YYYY

Key Family Contact or Main Caregiver at home

(If main caregiver is a domestic helper, please indicate the best person to contact)

Full Name*

Relationship*

Language/Dialect Spoken*

You can select more than one.

English

Mandarin

Malay

Tamil

Cantonese

Hokkien

Hainanese

Hakka

Teochew

Others

Language/Dialect Spoken (Others)*

Contact Number (Primary)*

Contact Type*

Home

Mobile

Office

Contact Number (Secondary)

Contact Type

Home

Mobile

Office

Referral Details

Please do not use initials

Referring Consultant/Registrar/GP*

Hospital/Dept*

Other Consultants involved*

Patient/Family agreed to referral*

Yes

Primary Diagnosis*

Histopathological Diagnosis*

Yes

Histopathological Diagnosis*

Sites of Metastases*

Yes

Sites of Metastases*

Date of Diagnosis*

Prognosis*

0-6 days

1-7 weeks

2-3 months

4-6 months

7-12 months

> 12 months

Present Condition*

Stable

Deteriorating

Is a MSW involved?*

Yes

Name of MSW*

Hospital Palliative Care team involved?*

Yes

Is patient currently under a hospice service?*

Yes

Name of Service*

Reason(s) for referral*

(more than 1 selection is allowed)

Pain & symptom control

Psychosocial support

Shared Care

Terminal care

Drug titration

Others

Others (specify)*

Drug titration (specify)*

Has patient been informed of diagnosis?*

Yes

Has family been informed of diagnosis?*

Yes

Has patient been informed of prognosis?*

Yes

Has family been informed of prognosis?*

Yes

Summary of Medical History

Name of Patient*

Summary of Medical History*

Please include relevant investigations e.g. CT/MRI/bone scan

Drop files here or

Max. file size: 10 MB.

For referrals to Star PALS, please attach the form here*

Drop files here or

Max. file size: 10 MB.

If you haven't downloaded the form in Step 1, please download it here.

Current Problems*

To add a new row, click on the “+” icon

Current Functional Status

(more than 1 selection is allowed for each section)

Mental status*

Alert

Drowsy

Comatose

Orientated

Confused

Demented

Mobility*

Independent

Ambulant with supervision

Ambulant with support

Chair-bound

Bed-bound

Feeding*

Independent

Needs supervision

Partially dependent

Totally dependent

To note*

Feeding tube

Intranasal O2

Cope loop

PCN

Tracheostomy

Colostomy

Ileostomy

Urinary catheter

Nil

Others

Feeding Tube

Ryle's/Freka/PEG

Intranasal O2

(L/min)

Cope loop

(Site: ________)

PCN

RT/LT/Bilateral

Others*

Current Medications

Drug Allergy*

Yes

Drug Allergy Description*

Current Medications*

To add a new row, click on the “+” icon

Name of Drug/Dose/Frequency

Reason Prescribed

Social Background

Please attach Social Report and Means Test if available.

Social Report and Means Test if available

Drop files here or

Accepted file types: pdf, png, jpg, gif, Max. file size: 20 MB, Max. files: 2.

Family Tree

Drop files here or

Accepted file types: pdf, png, jpg, gif, Max. file size: 20 MB, Max. files: 2.

Patient's concerns

Family's concerns

Referral Information

Name of doctor completing this form*

MCR No.*

Email*

Mobile No.*

Is this the first referral for the patient?*

Yes

Please indicate the number of times this patient has been referred*

Reason for previous rejection(s)*

Do you want a copy of the referral form?*

Yes

Name

This field is for validation purposes and should be left unchanged.

SHC Common Referral Form

This form will take some time to load because of its huge size. Therefore, once you click on the Next or Submit button, please do not do anything until you get to a new part of the form or a confirmation message.

Patient Details

Key Family Contact or Main Caregiver at home

Referral Details

Summary of Medical History

Current Functional Status

Current Medications

Social Background

Referral Information

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