Lung Cancer Support Service Referral Form

Lung Foundation Australia offers two telephone-based support services for patients, their families and carers at any stage of living with lung cancer - our Lung Cancer Support Nurse and our Lung Cancer Social Worker.

Once the referral is received by Lung Foundation Australia, our Information and Support team will make contact to book a first appointment.

Patients will typically speak to the nurse or social worker on three separate occasions, over a period of approximately four months. You will receive an email confirming booking of your patient’s initial phone appointment, and if urgent or important symptoms/issues are discussed, you will receive an email to the account nominated on the referral form. Upon completion of your patient’s engagement with the service, you will be provided with a report regarding the support provided and issues discussed, if applicable. The Lung Cancer Support Nurse and Social Worker programs are a confidential service and all correspondence is provided subject to patient consent.

*At this time we do not have the capacity to support patients requiring translator services.

Your Details

Title

First Name

Last Name

Contact Number

State

Referring Facility

Facility Postcode

Please choose one of the following: Are you a?

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Your patient’s information:

Please tick to confirm that your patient/family member or carer consents to being contacted by a Lung Foundation Australia staff member

Yes, my patient consents to being contacted by a Lung Foundation Australia staff member.

I would like to refer the patient/family member for a telephone appointment with: (you can select multiple options)

Lung Cancer Support NurseLung Cancer Social Worker

Your patient/family member is welcome to access both or one of the services.

Title

First Name

Last Name

Patient's email address (if known)

Date of Birth

Contact Number

State

Are there any issues regarding contact that Lung Foundation Australia staff should be aware of?

Are there other concerns or issues about your patient that the Lung Cancer Support Nurse and / or Social Worker should be aware of?

Your personal information will be collected, used and disclosed in accordance with our Privacy Policy and Data Collection Statement.

Contact Information