Patient / Carer Referral Form

Is it a patient or carer you are referring?
PatientCarer

Relationship to patient if carer

Has the patient or carer consented to this referral and to being contacted by a Specialist Myeloma Nurse?

Please note - our Specialist Myeloma Nurses can only make contact with someone if they have given consent for us to make contact with them.

YesNo

Please tell us the patient’s diagnosis (if carer, please state this in Other)
MyelomaSmouldering MyelomaPlasmacytomaMGUSOther

Please select what support our Specialist Myeloma Nurses can provide to the patient or carer you are referring (please select all that apply)
Local or online support groupsInformation seminars or education events (either locally or online)Resources (ie booklets)Verbal discussion and informationEmotional supportOther

Please indicate the best way for our Specialist Myeloma Nurses to make contact with the patient or carer
PhoneEmail
Booking a call to a Specialist Myeloma Nurse is also available to the patient/carer.