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.
Who is completing this form?
*
Patient
Family member or relative
treating medical practitioner
Name of the person completing this form
*
First Name
Last Name
E-mail address of the person completing the referral form
*
example@example.com
Section A: Patient's Information
(to be completed by either the treating medical practitioner or the patient or the patient's family member)
Date on which this form is being completed
*
-
Month
-
Day
Year
Date
Patient's Name
*
First Name
Last Name
Patient's Identity Number
*
Patient's Identity Document - DOCUMENT
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Patient's Gender
*
Please Select
Male
Female
Gender Neutral
Patient's Race
Please Select
Black
White
Coloured
Indian
Prefer not to say
Patient's Marital Status
Please Select
Single
Divorced
Married in COP
Married out of COP
Married ANC
I don't know
Patient's Religion
Patient's Primary Phone Number
*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Patient's Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Email
example@example.com
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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.)
Next of Kin Name
*
First Name
Last Name
Next of Kin Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Next of Kin E-mail Address
example@example.com
Next of Kin Phone Number
*
Please enter a valid phone number.
Relationship to the patient?
*
Next of Kin Name
First Name
Last Name
Next of Kin Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Next of Kin E-mail Address
example@example.com
Next of Kin Phone Number
Please enter a valid phone number.
Relationship to the patient?
Does a member of the family have a General Power of Attorney for the patient?
*
YES
NO
I DON'T KNOW
General Power of Attorney - DOCUMENT
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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)
Does the patient live alone?
*
YES
NO
I DON'T KNOW
If answered NO to the above, please provide the name of another household member.
First Name
Last Name
Who is the primary caregiver for the patient? (does not have to be a person living with the patient)
First Name
Last Name
Source of Income
Please Select
Salary
Pension
Social Grant
Other
No Fixed Income
Extent of Income
Please Select
Monthly less than R1000
Monthly R1000 - R4000
Monthly R4000 - R8000
Monthly more than R8000
Does the Patient have a valid Funeral Policy?
*
YES
NO
I DON'T KNOW
Name of the Funeral Policy Company
Contact Phone Number for funeral policy company
Please enter a valid phone number.
Funeral Policy - DOCUMENT
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Does the patient have a valid Advance Directive or Living Will?
*
YES
NO
I DON"T KNOW
Advanced Directive / Living Will - DOCUMENT
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Does the Patient have a Last Will/Testament?
*
YES
NO
I DON"T KNOW
Name of Executor of the Patient's Estate
First Name
Last Name
Phone Number for the Executor of the Patient's Estate
Please enter a valid phone number.
E-mail Address for the Executor of the Patient's Estate
example@example.com
Last Will / Testament- DOCUMENT
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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)
Name Of Medical Practitioner who is generally attending to the patient
First Name
Last Name
Phone Number of General Practitioner
Please enter a valid phone number.
E-mail Address of Medical Practitioner
example@example.com
Name of Specialist Practitioner (e.g. Oncologist)
First Name
Last Name
Phone Number of Specialist Practitioner (e.g. Oncologist)
Please enter a valid phone number.
E-mail Address of Specialist Practitioner (e.g. Oncologist)
example@example.com
Patient's Hospital Folder Number (particularly required for State Patients)
Additional Clinical Notes / X-Rays / Scans - DOCUMENT
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Name of Patient's Medical Aid Scheme (where applicable)
Patient's Medical Aid card - DOCUMENT
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Medical Aid Number (where applicable)
Name of Scheme Option (where applicable)
Dependent Number (where applicable)
D.1 - If the patient is a PRIVATE patient or covered by a MEDICAL AID SCHEME, the referring medical practitioner must agree to be available and remain responsible for the day to day oversight of the patient whilst they are in Hospice Care. Do you, as the medical practitioner, agree to avail yourself for this purpose?
*
YES
NO
If you are a patient or family member, tick this box (do not answer this question on behalf of the treating medical practitioner)
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.
If answer YES to D1 above, provide the name of the Medical Practitioner who is currently responsible for the patient and who will assume clinical responsibility for the patient whilst they are in Hospice Care.
First Name
Last Name
Phone Number of the Medical Practitioner who is currently responsible for the patient and who will assume clinical responsibility for the patient whilst they are in Hospice Care
Please enter a valid phone number.
Signature of the Medical Practitioner who is currently responsible for the patient and, where the answer to D1 above was YES, this is also the medical practitioner who will accept clinical responsibility for the patient whilst in Hospice Care.
Clear
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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)
Primary Illness
*
If cancer: primary focus
If cancer: secondary sites / deposits
Additional illnesses including chronic illnesses
*
ICD 10 code/s (if you know this information)
Category of care required
*
Please Select
Early Diagnosis
Palliative Care
Terminal Care
Reason/s for Hospice Referral (mark more than one option if applicable)
*
General Palliative Care
Symptom Control
Pain Management
Respite Care
Terminal Care
Home Care
24hr Support Centre Admission
Other
If answered Other to the above question, please state the reason below:
Please indicate briefly the patient's mobility status and their current functionality with respect to daily activities like eating and self care
*
Please list below any relevant medical interventions undertaken to date, including surgical procedures
*
Has the patient received Radiation Therapy for their illness?
*
YES
NO
I DON'T KNOW
If answered YES to the above - name the site/s of the Radiation Therapy
Has the patient received Chemo Therapy for their illness?
*
YES
NO
I DON'T KNOW
Has the patient received Hormone Therapy for their illness?
*
YES
NO
I DON'T KNOW
Please list the Patient's current medications - including Name, Strength and Dosage
*
Does the Patient suffer from any medicine idiosyncrasies or allergies?
*
YES
NO
I DON'T KNOW
If answered YES to the above, please list below:
*
Phone Number of the Patient's Pharmacy
Please enter a valid phone number.
Name of the Patient's Pharmacy
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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.
Name of the person completing the consent and indemnity
*
First Name
Last Name
Capacity of person completing the consent and indemnity
*
Patient
Next of Kin / Spouse
Family Member (Other)
Legal Guardian
Signature of person completing the consent and indemnity
*
Clear
Date
*
-
Month
-
Day
Year
Date
Consent and Indemnity signed at: (insert Region / District)
*
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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