Macmillan Cancer Support
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 *

Phone Number *

Email Address *

Gender *

Male

Female

Other

D.O.B *

GP Details *

Ethnic Group *

Prefered language *

Cancer Type *

SR1 Appropriate *

Yes

No

Brief details for referral: *

Are there any health and safety factors? *

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

SEND

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