Online referral form

ACCORD Hospice Referral Form

Medical - In Confidence

The referral form should be completed in full to allow us to provide an efficient and focused service to the patient. If appropriate, please ensure patients have had recent bloods taken.

The information received from the electronic referral will inform the Hospice Multi-disciplinary Team’s decision making. We will respond to the urgency of the referral and take full consideration of the patient’s identified needs. We will assess the referral and pass it to the most appropriate service.

New referrals are discussed daily by the Multi-disciplinary Team. The waiting list to prioritise inpatient admissions will be discussed daily at our morning clinical meeting.

Patients can be referred to the hospice by any healthcare professional, providing the referral has been discussed with and agreed to by the patient and the patient’s GP and / or hospital Consultant.

Download Referral Form

Patient Information

Main Carer/Next of Kin Details

Patients GP


Hospital Consultant(s)


Please select the score describing your patient using the following 0-4 guide.

Please note, a low score does not necessarily mean your patient will not be a priority admission. Adapted from STAS (Support Team Assessment Schedule)


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