Ambulance Wish Referral Form
The form is 2 pages long and will take 10-15 minutes to complete.
Who is Referring the person?
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Please Select
Healthcare Professional - Looking after the patient
Healthcare Professional - Community
Healthcare Professional - Hospice
Close Family
Friend of the Patient.
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
NHS Number
Patient Diagnosis
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Home Address
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Street Address
Street Address Line 2
City
County
Post Code
Current Location if not home
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Patients or Family Contact Number
*
About the Wish
What would the patient like to do?
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Why would they like to do this?
*
Location of the Wish including postcode
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How long will the wish last? (Approximately)
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Any escorts travelling with patient (family member, friend, partner etc)
*
We can take one person as routine but discussion is required on needing 2. Max of 2 escorts due to weight limits and space.
Medical Information
Lead Clinicians Name (GP or Consultant)
*
First Name
Last Name
Email for Clinicians Name
*
Hospice or Community Palliative Care Team Contact Details
*
Does the patient have the mobility to complete the journey without ambulance assistance?
*
YES
NO
What is the Goal of palliation of symptoms?
Patient aware of goal of care?
*
YES
NO
Family aware of goal of care?
*
YES
NO
Other
Patient's prognosis considered < 4 weeks
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YES
NO
Patient's prognosis considered 12 Months - 1 Month?
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YES
NO
Has a DNACPR form has been completed?
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YES
NO
Other
Has a RESPECT form has been completed?
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YES
NO
Other
Current mobility. When planning a wish we need to assess access. Is the patient...
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Bedbound
Can use a wheelchair for transfers
Uses standard wheelchair
Uses a electric wheelchair
Other
Current mobility. How does the patient transfer
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Patient Slide
Full Hoist
Standing Hoist
Sara Steady (Or similar)
Walking Frame or other walking aids
Fully Mobile
Other
Patients Weight (KG)
Please list any medications that the patient may require during the wish, including route of administration. This enables us to identify the grade of volunteer ambulance clinician needed. (With regards to analgesia, please consider if what they are taking now when in a comfortable environment will be as effective when out on the wish i.e. the ambulance journey can be bumpy, The movement of stretcher/wheelchair over bumps or uneven surfaces etc)
Is the patient likely to require the use of suction?
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YES
NO
Other
Does the patient have a tracheostomy?
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YES
NO
Other
Please list any possible complications when moving the patient such as pathological fracture, cord compression, c-spine instability.
Is the patient infectious?
*
YES
NO
Other
To help us plan any toileting requirements during the wish, please tell us if the patient has a catheter, stoma, wears pads etc. Or, if the patient uses the toilet, are they able to weight bear to transfer from stretcher/wheelchair onto the toilet?
*
Is the patient for escalation of care?
*
NO
YES (explain)
Instruction should patient become unwell during journey (e.g. return home/ to place of care/ hospital etc )
*
Instruction should patient die during journey (e.g. return home/ to place of care )
*
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Closing Questions
Can the Wish trip be posted that it is taking place without reviling the patients identity?
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YES
NO
Other
Can Photos be taken for a wish memory book?
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YES
NO
Any other information?
Helpful Information
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Completion of the Form
The information provided in this form must be completed accurately and to the best of your ability. Any incomplete or inaccurate information may result in delays to the wish and its associated process.
Person completing the form
*
First Name
Last Name
Role
*
Email Address
*
Phone number
*
Signature
*
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