HCP Referral

HCP Referral Form

Please fill out the form below to refer your patient.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Patient's Details

Patient’s Name*
Patient’s Date of Birth

Referrer’s Details

Please note: We are not an emergency service. If you need emergency input regarding this referral please link with the patient’s GP or contact Emergency Services as appropriate.

Make a real difference in someone's life....

Remember someone

Supporting Cancer Care West in memory of a loved one is a touching way to celebrate their life and create a lasting legacy that helps people affected by cancer. Every gift we receive will help us to be there for more people through their experience of cancer. With your support, you are helping us realise our vision that no-one has to go through cancer alone.

There are a number of ways your loved one can be remembered

Donate in memory

Making a donation in memory of someone is a positive way to celebrate their life. These donations will honour the life of the person you have lost, whilst making a real difference to someone affected by cancer. You can make a one off donation or set up a regular donation.

Donate online now

Send us a cheque or postal order to Cancer Care West, University Hospital Galway, Galway.

Donate over the phone by ringing 091 545 000

Donations in lieu of flowers

People can also request donations to Cancer Care West in lieu of flowers at a funeral or memorial service. If this is something you are considering, you might like to include this wording in your loved one’s death notice: Donations in lieu of flowers to Cancer Care West, University Hospital Galway.

Challenge Yourself

It can be overwhelming to loose someone you love but there may come a time when you would like to take part in a challenging event in their memory. We have a range of events for you to take part in to celebrate their life and at the same time raise money to help Cancer Care West continue our work

Find an Event

Organise your own activity

Organising your own event or activity in memory of a loved one can be a wonderful way to celebrate their life. We are here to support you and to help you get started, to find out more please contact our fundraising team – [email protected] or 091 545000  or click here for more information on how you can orgainise your own event

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