• Patient Referral

    21 Old Stellenbosch Road, Somerset West. Tel: 021 852 4608. E-Mail: nursing@helderberghospice.org.za
  • Helderberg Hospice Patient Request for Referral

    Every patient that is in need of our specialist palliative care service can either approach us directly or can be referred to us by their treating medical practitioner or by a family member or relative. Irrespective of who refers the patient to our service, there is certain personal, medical and socio-economic information which we require in order to fully assess the patient's suitability for Hospice Services. Please note that, as a Non-Profit Organisation, our service capacity is sometimes limited and, it may not always be possible to accept all patients onto service immediately and, where appropriate, the admission may be deferred for a period of time or referred to an alternate institution for further suitable care or support. Once we receive your completed referral request form, we promise to get back to you within 48 working hours to advise you of the status of your referral. Should the information provided be insufficient for us to make a determination around suitability for service, we will request further information from the patient, the patient's family or the patient's care team. In these instances, it may take a further 48 working hours to finalise an admission. In any event, you can expect a referral for admission to take between 2 to 4 working days. Please note that we do not process referrals for admissions, of new patients, on weekends or public holidays.
  • Section A: Patient's Information

    (to be completed by either the treating medical practitioner or the patient or the patient's family member)
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  • Section B: Next of Kin Information

    (to be completed by either the patient, the patient's family member or the treating medical practitioner. We require at least one next of kin's information.)
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  • Section C: Income Information

    (to be completed by either the patient or the family member. If you are the treating medical practitioner and are completing Section C of this patient referral, you may leave this section blank if you do not have this information, it will however be required from the patient or family to complete the referral process prior to confirmation of admission to our service)
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  • Section D: Patient's Care Team Information

    (to be completed by either the treating medical practitioner, the patient or the patient's family member - please note that there are portions of this section that require the treating medical practitioner sign acknowledgement of care - please only sign this acknowledgement if you are the treating medical practitioner concerned. Family members or patients are instructed NOT to sign on behalf of the practitioners)
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  • Important Notice

    If you have answered "NO to D1 above, please note that Helderberg Hospice will NOT be able to conclude your patient referral. You will be able to complete the referral forms and SUBMIT for review, however, It is a requirement for admission to our service that all private and medical aid scheme patients remain under care from their referring medical practitioner for the duration of their admission to our service. If you are completing this referral as a Medical Practitioner on behalf of a State subsidised patient, you do not need to stand cover for the patient as State Subsidised Patients are covered by our resident Hospice Medical Officer whilst in our care.
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  • Section D: Medical Diagnosis of the Patient

    (to be completed by either the treating medical practitioner, the patient or the patient's family member - it is imperative that this section contains accurate and comprehensive medical information in order for Hospice to fully assess the patient's needs and to allow us to quickly and accurately allocate Hospice resources to the patient - it is preferable that this section is completed by the medical professional who is most knowledgeable with the patient's condition)
  • Section E: Patient / Next of Kin Consent Form and Indemnity

    I hereby give my permission for Helderberg Hospice to be involved in my or my family member’scare and agree that the members of the Palliative care team may visit me / my family member. I give permission for the Hospice Staff to transport medication on my behalf when necessary. I agree and accept that, in my capacity as patient / member of the patient’s family, I will not hold any staff member or volunteer representing Helderberg Hospice liable for any harm suffered, loss incurred or injuriessustained by the patient or family member as a result of participation in caring for the patient at home, in transit or in the Support Centre.I hereby indemnify Helderberg Hospice against claims arising from the above by any Hospice employees, nursing staff and / or volunteers whilst making use of any facilities supplied by Helderberg Hospice.I agree that, Helderberg Hospice reserves the right to bill for services rendered which are not covered by the medical aid scheme, where applicable.Helderberg Hospice reserves the right to waive any fees associated with patient care where applicable.
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  • Personal Information

    By providing Helderberg Hospice with your personal information and documentation, as set out herein, you voluntarily consent to it being reasonably retained, stored and processed. Your further acknowledge that such information is retained and processed for the lawful purposes and objectives of the organisation and that the information may be retained in a database to allow the organisation to communicate with you in future regarding prospective objectives / donations / interests. Such personal information will remain confidential and will not be shared with any third parties without your consent. All reasonable measures will be taken to safeguard your personal information. Should you object to our retention and processing of your personal information or should you wish to rectify your personal information retained with us, kindly inform us via e-mail at data@helderberghospice.org.za
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