Cancer Society - Domain Lodge Referral Form
Referral form for patients requiring accommodation at Domain Lodge (Auckland) during treatment. To be completed by hospital staff only.

If you have any questions, please email reception@akcansoc.org.nz or phone 09 308 0160.
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  • Patient's details

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  • Put N/A if not applicable.
  • Alternative / emergency contact

  • Referrer's details

  • Patient's details continued

    Please refer to full Criteria and Information for Referrers on the Cancer Society website.

    Reminder: Domain Lodge functions like a motel
    - It is not a health care facility and is unsuitable for people who require a high level of care.
    - The guest must be independently self-caring or able to manage with assistance from their supporter.
    - It is the guest's responsibility to get themselves to and from treatment (a distance of 500 metres over uneven ground).
    - Domain Lodge must be informed of any known hazards (e.g. police/justice system, infection, aggression, mental health issues) that may pose a safety risk to the guest, staff or other guests.
  • Put N/A if not applicable.
  • (If non cancer.) Put N/A if not applicable
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  • Write "not known" if you don't know.
  • Treatment

  • Select all that apply
  • Radiotherapy treatment

    If the patient is undergoing radiotherapy treatment during their stay at Domain Lodge, you must complete this section.
    If the patient is not undergoing radiotherapy treatment please continue to the next section.
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  • Chemotherapy treatment

    If the patient is undergoing chemotherapy treatment during their stay at Domain Lodge, you must complete this section.
    If the patient is not undergoing chemotherapy treatment please continue to the next section.
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  • Surgery or other treatment

    If the patient is undergoing surgery or other treatment during their stay at Domain Lodge, you must complete this section.
    If the patient is not undergoing surgery or other treatment please continue to the next section.
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  • Private treatment

  • This helps us manage ongoing bookings
  • Any additional information