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Macmillan Welfare Benefits
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Referral Form
Are you referring yourself or a client?
*
For My Self
For a Client/Family member.
Referrer's Details
Referrer's Name:
*
Referrer's Organisation
*
Referrer's Email Address
*
Referrer's Contact Details
*
Date of Referral
*
Care Coordinators Name:
*
Patient Details
Title
*
Mr
Mrs
Miss
Ms
Dr.
Prof.
Mx
First Name
*
Surname
*
Address
*
Postcode
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Phone Number
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Email Address
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Gender
*
Male
Female
Other
D.O.B
*
GP Details
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Ethnic Group
*
Prefered language
*
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?
*
Yes
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