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Patient\'s Name: Address: Postal Code: Date of Birth:All Sites and FacilitiesPhone Number:Pain Assessment: Page 1 of 2 (or Patient Label or Stamp)Palliative Performance Scale %: Stable Rapid Decline

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How to fill out palliative care program request

01

Contact the palliative care program to inquire about the request process

02

Fill out the required forms with personal information and medical history

03

Submit any additional documentation requested by the program, such as current medication list or advance directives

04

Await confirmation of acceptance into the palliative care program and next steps for care

Who needs palliative care program request?

01

Patients with serious illnesses such as cancer, heart failure, or advanced dementia

02

Patients experiencing symptoms that are difficult to manage, such as pain, shortness of breath, or nausea

03

Patients and families seeking comprehensive support for physical, emotional, and spiritual needs during a serious illness

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What is palliative care program request?

A palliative care program request is a formal application submitted to request palliative care services for a patient who is dealing with a serious illness.

Who is required to file palliative care program request?

The family members or legal guardians of a patient, along with the healthcare provider, are typically required to file a palliative care program request.

How to fill out palliative care program request?

To fill out a palliative care program request, one must provide the patient's personal information, medical history, current condition, and reasons for seeking palliative care services.

What is the purpose of palliative care program request?

The purpose of a palliative care program request is to ensure that a patient receives comprehensive and compassionate care to improve their quality of life while dealing with a serious illness.

What information must be reported on palliative care program request?

The palliative care program request must include the patient's name, contact information, medical history, current condition, treatment preferences, and any specific goals for care.

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