{"content":"This form will take 3 to 7 minutes to fill and it will assist us in managing the patient and referral data.\n\nPlease fill in with as much detail as possible about your patient and attach any relevant medical history, all pertinent scans/imaging, and any pertinent consults from other physicians or specialists.\n\n**This referral form must be filled by a Registered Medical Practitioner with Malaysian Medical Council (MMC).**\n\nIf you prefer to download the form and fill it in manually, please click >>> [Referral Form](upload/Patients_Referral_Form_2023.pdf)\n\n  \n\nDoctor's Tel. No. \\*\n\nPatient's Name \\*\n\nGender \\*\n\nRace \\*\n\nOthers \\*\n\nAge \\*\n\nIC No. \\*\n\nReligion \\*\n\nLanguage Spoken \\*\n\nNext of Kin \\*\n\nTel. No. Hse. \\*\n\nTel. No. Mobile \\*\n\nArea/City \\*\n\nAddress \\*\n\nPost Code \\*\n\nHistory of Illness \\*\n\nIf Cancer, what type of cancer? \\*\n\nStage \\*\n\nIf Non-Cancer, what type of disease? \\*\n\nIf Other Non-Cancer Case, provide the details of disease/illness \\*\n\nDuration \\*\n\nTreatment \\*\n\nMedication \\*\n\nAllergies \\*\n\nPresent Problems \\*\n\nAny scans, reports or imaging to be attached? \\*\n\nIs the patient informed of the diagnosis? \\*\n\nIs the patient informed of the prognosis? \\*\n\nIs this patient/caregiver agreeable to receiving hospice care? \\*\n\nHas the patient been referred to Klinik Kesihatan Domiciliary Palliative Care?\\*\n\n_\\*If Yes, Pertubuhan Hospice Negeri Sembilan will not accept this Patient. \\*_","original_url":"https://pms.phns.org.my/","word_count":225,"key_claims":["Address \\*","provide the details of disease/illness \\*","Registered","Contact information available"],"content_summary":"This form will take 3 to 7 minutes to fill and it will assist us in managing the patient and referral data. Please fill in with as much detail as possible about your patient and attach any relevant medical history, all pertinent scans/imaging, and any pertinent consults from other physicians or spec","expertise_signals":[]}