Palliative Home Care Registration Form

I am making the referral for:*

My patientMyselfFamily Member / Relative / FriendOther

Patient Name*

Full Name

Gender*

COVID-19 Status*

Patient Phone Number*

Weight (Optional)

Estimated weight if unsure.

Contact Person*

Handphone*

Email*

example@example.com

Referring Clinic or Institution*

Contact Number*

Referring Physician's Name:*

Referring Physician's MCR No.:*

Tentative date of Palliative Service Commencement:*

Date

Upload Case Notes / Memos or other Relevant Documents:*

Preferred service type:*

For Palliative Program you will be redirected to another page for payment processing.

Speedoc Palliative Package Includes:

($2,160 inc. 8% GST)

Components	Quantity	Description	Remarks
Doctor Home Visit	4 Visits	45mins / visit
Nurse Home Visit	4 Visits	45mins / visit
Medications	20 units	1 unit: Tablets (2 weeks amount) or; 1 ampoule / vial / bottle of syrup 2 units: Patch	Only for drugs on Speedoc Palliative drug list*** (eg. pain relief, nausea medication, secretions management medications etc) Excludes injectable antibiotics.
Procedures	4 units	Applicable procedures 1 unit: Injection Subcutaneous Cannulation Oral Suctioning NGT Insertion Simple Wound Dressing 2 units: Complex Wound Dressing	Simple Wound Dressing: Only for 1 wound site (Stage 1 and 2 wounds) Complex wound Dressing: For multiple wound sites (Stage 3, 4 and unstageable wounds, also for multiple wound sites regardless of stages).
Equipment Rental	2 weeks (in 1-week block period)	Includes delivery charge of equipment.	Subjected to availability. Only for Infusion pumps and Oxygen concentrator.

***All package components expires 3 months from date of purchase.
If any of the components are exhausted, individual service item price will be charge for that component.
Insurance Coverage: Certain insurance plans may offer coverage for these services. To verify your specific coverage, kindly reach out to your insurance representative or provider for confirmation.
Response Time: We kindly request a period of 2 working days to respond to your submission and address any inquiries or requests.
Assigned Palliative Team: Upon confirmation of service by our staff, we will provide you with the details of the assigned Palliative team.

Does the patient require an ambulance or medical transportation?*

YesNo

When would you prefer to schedule the ambulance pickup?

Price Estimation (There will be a 50% surcharge for cancellations 1 hour before the scheduled visit time. 100% surcharge will apply if staff is already on site)

Palliative Care