PalCare

04/09/2010

Referral Form

Patient Details

*Mandatory Fields

Hospice Service referred To:

NHI Number:

Please enter in this Format Ex NHN2345

Referral Date: (Please enter Date in dd/mm/yyyy format)

(DD/MM/YYYY) *

Title:

FamilyName:

First Name:

Preferred Name:

Second Name:

Third Name:

Address line 1:

Address Line 2:

Suburb:

City/Town:

Country/Region:

Domicile:

Email:

Home Phone:

Mobile:

Alternative Phone Number:

Fax:

DOB: (Please enter Date in dd/mm/yyyy format)

(DD/MM/YYYY)

Ethnic Group:

Gender:

Country of Birth:

NZ Residency:

Occupation:

Specific Cultural Needs:

Language Spoken:

Patient Lives with:

Interpreter Required:

Community Services Card:

Insurance Status:

Private Health Insurance:

Diagnosis Type:

Diagnosis/Operation/Accident Description:

Diagnosis Date: (Please select Month and enter year in yyyy format)

Allergies/ Sensitivities:

Current Issues:

Relevant Social History:

Reason For Referral:

Symptom Control
Respite Care
Counselling
End Stage Care

Is Advanced Care Plan:

Other Services Involved:

District Nurses	OT	Social Worker
Iwi Provider	Physio	Home Support
Cancer Society	Oncology
Other

Iwi:

Carer Support:

Patient Aware of Referral:

Patient Aware of Diagnosis:

Insight into Prognosis:

	Referrer Details
Referrer Name:	*
Referral Source:	*


Phone:	*
Fax:
Date of Admission: (Please enter Date in dd/mm/yyyy format) (If Referring Agency - Hospital)	(dd/mm/yyyy)
Department: (If Referring Agency - Hospital)
	GP Details	Select GP
Title:
Surname:
Given Name:
Clinic Name:
Address:
Suburb:
City/Town:
Post Code:
Phone:
Fax:
Email:
I am willing to participate in multi disciplinary care plans and case conferences:
	Specialist Details	Select a Specialist
Title:
Surname:
Given Name:
Position:
Hospital/Clinic Name:
Address:
Suburb:
City/Town:
Post Code:
Phone:
Fax:
Email:
	Primary Carer Details
Primary Carer Available:	Yes No
Title:
Surname:
Given Name:
Address1:
Address2:
Suburb:
City/Town:
Post Code:
Phone:
Mobile:
Email:
Relationship: