Hospice Wairarapa Referral Form
Urgency
Within 24 hours
Within a week
Client Information
(The person who needs care)
Name
First Name
Last Name
Type of Referral
Patient
Caregiver / Whānau
Self Referral
Date of Birth
-
Day
-
Month
Year
Date
NHI number (if known)
Gender
Please Select
Male
Female
Non-binary
Prefer not to say
Ethnicity
Phone Number
-
Area Code
Phone Number
Email
Address
Street Address
Street Address Line 2
City
Postal / Zip Code
NHI (if known)
Carer or other Contact
First Name
Last Name
Relationship to Client
Parents, guardian, mother, father, family relatives
Phone number
-
Area Code
Phone Number
Health Status
(If relevant)
Primary Diagnosis
Diagnosis Date
-
Day
-
Month
Year
Date
Other medical conditions
Referral Details
Referrer
Note: Can be self referral
Referral Date
-
Day
-
Month
Year
Date
Reason for Referral
Referer Phone Number
-
Area Code
Phone Number
Referer Email
Other Services Involved (if any)
District Nurses
Oncology District Nurses
Cancer Society
Kahukura Palliative Nurses
FOCUS
DHB Social Worker
Consent
Client is aware and has consented to this referral to Hospice Wairarapa
Client consents to be discussed at Wairarapa Palliative Care Services Team meeting held with Te Whatu Ora Staff
Are there any visiting risk factors e.g. Acess/ dogs etc. Please specify:
Referer Signature
Date Signed
-
Day
-
Month
Year
Date
Please note Hospice Wairarapa does not provide a medical service, we provide a psycho-social and bereavement service. For medical referals please contact the Kahukura Palliative Care Team Ph 06 370 8436 Mobile 027 230 7427 8.00-4.30pm, 7 days.
Submit
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