Referral Form

Home Patient Services Referrals Referral Form

This is a non-urgent referral form. If your referral requires urgent attention, please contact us on 0800 473 6005 or 03 473 6005.

Otago Community Hospice provides specialist palliative care to people with a life limiting illness. Our multidisciplinary team works in partnership with the patient, family and community health providers.

You can refer anyone living or staying in Otago with:

  • Active, progressive disease no longer responsive to curative treatment with a prognosis likely less than twelve months.

And

  • Complex symptoms (physical, social, emotional or spiritual) resistant to standard care in the community

Once you have submitted your referral successfully, you will receive a confirmation email with details of the referral. If you do not receive acknowledgement email please call us on 0800 473 6005 or 03 473 6005.

 

Note - fields highlighted with an * must be completed for successful submission of this form.

Urgency Rating *

Urgency Rating is required
If this referral is urgent please contact us on 0800 473 6005 or 03 473 6005

Patient Details

Name is required
Date Of Birth is required
Address is required

Personal Representative

GP Details

GP is required
Phone is required

Consents

Patient Consents to Referral (Without patient consent this referral cannot be progressed) is required
Family Aware of Referral is required
GP Aware of referral is required

Diagnosis

Relevant Medical History (including allergies) is required

Current problems requiring specialist palliative care

Services currently involved

Supporting Information

If able to, please provide:

  • Documentation confirming diagnosis
  • Current medication list, including dose and frequency
  • Recent correspondence from hospital specialist
  • Most recent radiology reports and blood test results
# 1
Add

Referrers Details

Name of referrer is required
Designation is required
Email is required
Agree Terms is required