Submit a Referral

Demonstration form

This is a demo site — no real referral is submitted. Completing this form writes a sample entry to your browser's localStorage, which you can view in the admin dashboard. In a live system, this would create a case record and notify the intake coordinator.

Referring clinician

Details of the physician or clinical team making this referral.

First name *

Last name *

Clinical email *

Direct phone number *

Practice or hospital *

Specialty

NPI number (optional)

10-digit National Provider Identifier, if applicable.

Patient information

Basic demographic details — do not include clinical notes here, use the clinical summary field below.

Patient first name *

Patient last name *

Date of birth *

Gender

Patient address

Patient / family phone *

Insurance / payer

Clinical details

Primary diagnosis and care needs to help us prepare the right IDG team.

Primary diagnosis *

Estimated prognosis

Preferred care setting *

Urgency of referral *

Clinical summary *

Care needs identified (select all that apply)

Pain management Symptom control (nausea, breathlessness, fatigue) Psychological support Spiritual / chaplaincy care Social work / family support Advance care planning Bereavement counselling for family Medication management

Emergency contact / next of kin

Name

Relationship to patient

Contact phone

Additional notes

✓

Referral received

Thank you — your referral has been logged in our intake system. Our intake coordinator will contact you within one business day to arrange the initial assessment visit.

Demonstration acknowledgement This is a sample website built by RG Consulting to demonstrate how a hospice intake management system could work for your organisation. No real referral has been submitted. The sample data has been written to your browser's localStorage — visit the admin dashboard to see how it appears in the case queue.

Eligibility criteria

Patients are eligible for our programme when a physician certifies a prognosis of six months or less if the illness runs its normal course. We serve: