Specialist Palliative Care Referral Form

Please ensure ALL sections of the referral form are completed in full.

  • The referral form must be signed by a doctor OR by a palliative care team member currently involved in the patient’s care
  • The referrer should sign and print their name
  • If the Urgency of Referral is marked as “2 working days”, the referrer must contact the Community Palliative Care Team (CPCT) by phone and speak to a CPCT nurse manager.
    • Harold’s Cross 01-406 8700
    • Blackrock Hospice 01-206 400
    • Wicklow Hospice 01-406 8888

Please attach any available information in relation to treatment or clinical updates, including:

  • CT/MRI/Other radiology reports
  • Lab reports
  • Hospital discharge summaries
  • Hospital outpatient clinic letters
  • Any other relevant information

Completed referral forms plus supporting documentation should be emailed to

  • Harold’s Cross: communityharoldscross@olh.ie
  • Blackrock Hospice: blackrockhospice@olh.ie
  • Wicklow Hospice: wicklowhospice@olh.ie

Click here to download Specialist Palliative Care Referral Form