Inpatient Chaplaincy Referral Form

Unique ID

I am...(Required)

My Email Address(Required)

Enter Email Confirm Email

Patient's Full Name(Required)

Forename Surname

Patient's Date of Birth(Required)

Does the patient know you are making the referral?(Required)

Yes

Admission Date

Hospital

Ward at Hull Royal Infirmary

Ward at Castle Hill Hospital

Patient's faith, belief or Christian denomination

Other faith or belief

Will the patient receive Sacrament of the Sick before admission?

Yes

Don't know

What is the name of the Parish Priest?

This referral is for:(Required)

this inpatient stay only

this and any future inpatient stays

We take your privacy, and the security and confidentiality of healthcare data, extremely seriously. This website has been built with security and confidentiality in mind.

Your IP address is never logged in our database.
Any person identifiable data you submit via this form is stored on a secure database server in England, which only the relevant authorised healthcare professionals can access.
All email notifications containing person identifiable data are sent securely through NHSmail.
Our processes for collecting data via this website have been approved by the Hull University Teaching Hospitals NHS Trust Information Governance Committee.
We are fully compliant with GDPR and the Data Protection Act 2018.
If you have any questions or concerns about this form, please contact the Digital Communications Team.