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Referral Form
Are you referring yourself or a client?
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Self
Client
Referrer's Name:
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Referrer's Organisation
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Referrer's Email Address
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Referrer's Contact Details
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Date of Referral
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Care Coordinators Name:
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Title
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Mr
Mrs
Miss
Ms
Dr.
Prof.
Mx
First Name
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Surname
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Email address
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Address
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Postcode
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Phone Number
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D.O.B
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Gender
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Male
Female
Other
GP Details
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Ethnic Group
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Prefered language
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Cancer Type
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SR1 Appropriate
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Yes
No
Brief details for referral:
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Are there any health and safety factors?
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Does the person named above give verbal consent for a referral to be made to the Staffordshire Macmillan Welfare Benefits Service and to share appropriate medical information with the service and relevant third parties for the purpose of claiming benefits?
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Yes
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First Name