Page 11 - Hospice Savannah
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                           This patient has requested a referral to The Steward Center for Palliative Care for management of symptoms resulting from their chronic, progressive illness. The patient will be treated as needed in the SCPC out-patient clinic and will continue to attend regularly scheduled appointments in the referring physician’s office. The referring physician’s office will be provided with physician notes for each patient visit.
Patient Name....................................................................................................SSN........................................................... Address ...................................................................................................................................................................................... DOB ......................................... Race ............................ Sex..............................Phone No............................................. Primary Insurance .........................................................................................Number ................................................ Secondary Insurance...................................................................................Number ................................................
Please identify the patient’s progressive illness(es):
Advanced Heart Failure COPD Dementia HIV/AIDS Advanced Liver Disease/Cirrhosis
Pulmonary Fibrosis Cancer Advanced Kidney Disease ALS Advanced Parkinson’s Disease
          Other............................................................................................................................................................................................
Types of symptoms treated include, but are not limited to: Anxiety, Debilitating Fatigue, Depressed Mood, Feeding Difficulties / Weight Loss, Insomnia, Loss of Appetite, Nausea and Vomiting, Pain, and Shortness of Breath. Goals of care including Advance Directive and POLST forms will also be discussed.
Please provide patient demographics, insurance information, and most recent visit notes, labs, and medications with this referral form. Return via fax to 912-298-0306
Referring Physician’s Name....................................................................Phone..................................................... Fax ............................................................ Referring Physician’s Signature ................................................................................................................................ Date ..............................................................................................................................................................................................


























































































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