Referral Form - Hospice South Auckland

Patient:
First Name:*
Middle Name:
Last Name:*
Address:*	Phone Number:*
Date of Birth:*	NHI:
Ethnicity:	First Language:
	Is an Interpreter Needed? Yes No

Main Carer:
First Name:	Last Name:
Address:	Phone: Relationship to Patient:

General Practitioner
First Name:		Last Name:
Address:
Phone:	GP Notified of Referral
	No	Yes Date:

Diagnosis or Active Disease Process (include any therapies / procedures to date eg surgery, chemotherapy, radiotherapy, complementary therapies)

Date of Diagnosis:
Other Medical History:
Current Medications:
Drug Allergies and Intolerances:

Current Needs or Reasons for this Referral:
Patient Needs:
Physical (describe):
Psychosocial (describe):
Other (describe):

Carer Needs:
Physical (describe):
Psychosocial (describe):
Other (describe):

Current Circumstances:	Patient Aware?		Family Aware?
Awareness of Diagnosis	Yes	No	Yes	No
Awareness of Prognosis	Yes	No	Yes	No
Understanding of Palliative Care Approach	Yes	No	Yes	No

Other Services Currently Involved:
District Nurse	Yes	No
Other Hospice	Yes	No
Social Worker	Yes	No
Interpreter	Yes	No
Oncology Nurse	Yes	No
Cancer Society	Yes	No

Checklist: Please Choose the Document:
Documentation Confirming Basis of Diagnosis
Most Recent Blood Test Results
Operation Report
Most Recent Hospital Specialist
Most Recent Radiology Reports

1. Consent not indicated and / or referrer details absent.

2. There is insufficient supporting information


If this Referral needs urgent attention (i.e. initial contact within 24 to 48 hours) Please ring the Hospice directly on 09 640-0025
Your Name:	Phone Number:
Fax Number:	Relationship to Patient:

Change Image
Write the characters in the image above