Lake Taupo Hospice Self Referral Form

Hospice and Specialist Palliative Care Self Referral Form

Please fill out the below information in as much detail as you are able.
This form is for patients within the Lake Taupō region (including Tūrangi & Mangakino) to be referred to hospice care by a family member or themselves.
Does the patient agree to this referral or do you have the authority to complete this form on their behalf (EPOA)?

YesNo
If the answer to this question is NO, then we will be unable to progress with this referral.
Personal Details
Patient Name *

First Name/sSurname
Contact Phone number
Please enter the best contact number (landline/mobile)
Contact Email*
Address*

Street Address

Street Address Line 2

City/TownState / Province

Postal / Zip Code
Date of Birth*

DayMonthYear
Date
Gender
Ethnicity
Country of Birth
Next of Kin Details
Next of Kin name*

First NameLast Name
Contact Email
Contact Phone number*
Medical Details
NHI number (if known)
Name of GP and Practice
What is the current diagnosis of the patient?
How can Lake Taupō Hospice help?
Referrer Details (if different from patient or next of kin)

If the patient is not the referrer or is unable to discuss details about the referral please fill in the below section. Please note that the patient must have given consent for the referrer to discuss their details with our clinical team.
Referrer Details

First NameLast Name
Contact Email
Contact Phone number
Should be Empty:

Hospice and Specialist Palliative Care Self Referral Form