EmailMe Form - Cancer Society - Domain Lodge Referral Form

Today's date *

DD / MM / YYYY

Patient's details

Patient name *

First Last

Date of birth *

DD / MM / YYYY

NHI Number *

Address *

Street Address City State / Province / Region Postal / Zip Code

Home Phone

Cell Phone

Put N/A if not applicable.

Email

Alternative / emergency contact

Emergency contact name

First Last

Relationship to patient

Cellphone/Phone

Email

Referrer's details

Referrer name *

First Last

Position *

Email *

Location *

ACH

Northland

Other

Department *

Phone Number *

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.

Have you read the above? *

Yes

Diagnosis *

Put N/A if not applicable.

Other *

(If non cancer.) Put N/A if not applicable

SIM and planning appointment *

DD / MM / YYYY

Will accommodation be required for the SIM and planning appointment? *

Yes

No

Date arriving for SIM and planning appointment

DD / MM / YYYY

Date leaving for SIM and planning appointment

DD / MM / YYYY

NTA Number

NTA paperwork completed? *

Yes

No

If NTA paperwork hasn't been completed, please specify why:

Will the guest bring a support person? (One only. MUST be able-bodied) *

Yes

No

Support person name *

Write "not known" if you don't know.

Relationship to patient *

Spouse/Partner

Friend

Family Member

Other

Does the patient need a walk in shower? *

Yes

No

If YES, please state reason *

Treatment

Treatment type *

Surgery

Radiotherapy

Chemotherapy

Other

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.

Unit

Extension Number

Date Arriving

DD / MM / YYYY

Start Date

DD / MM / YYYY

Finish Date

DD / MM / YYYY

Date Leaving

DD / MM / YYYY

Date (re book)

DD / MM / YYYY

Total Number of Appointments

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.

Date Arriving

DD / MM / YYYY

Start Date

DD / MM / YYYY

Finish Date

DD / MM / YYYY

Date Leaving

DD / MM / YYYY

Total Number of Appointments:

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.

Date Arriving

DD / MM / YYYY

Date Leaving

DD / MM / YYYY

Treatment unit or ward

Private treatment

Is the guest receiving private treatment? *

Yes

No

Which treatment centre is the patient attending? *

Auckland Radiation Oncology

Other (please specify)

Please provide the name of the patient's closest DHB *

Have you discussed medical insurance accommodation allowance? *

Yes

No

If NO, why not? *

If YES, please indicate the amount in their policy *

This helps us manage ongoing bookings

Patient's details

Alternative / emergency contact

Referrer's details

Patient's details continued

Treatment

Radiotherapy treatment

Chemotherapy treatment

Surgery or other treatment

Private treatment

Any additional information