EmailMe Form - Updated Cancer Society Auckland SC Ref Form

Please check the services being referred to *

Community Liaison Nursing

Counselling and Psychology

Volunteer Driving

Check those that apply

Patient Details

Please fill out the patient's details in this section.

Name *

First Last

Title (e.g. Mr/Mrs)

Date of Birth *

DD / MM / YYYY

NHI Number *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Phone *

Please provide the phone number you are most available on

Mobile

Ethnicity

NZ Resident

Yes

No

Speaks English *

Yes

No

Don't know

Treatment *

Surgery

Chemotherapy

Radiation Therapy

Other

Any comments about treatment

Social Situation *

Has the patient agreed to contact by the Cancer Society? *

Yes

No

Can Cancer Society staff leave a phone message saying who they are? *

Yes

No

Referrer details

Please fill out the referrer's details in this section.

Referrer Name *

Position *

Phone *

Email

Location *

GP Details

Please fill out the details of the patient's GP in this section.

Name *

Organisation *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Phone No *

Other Agencies Involved

Community Liaison Nursing & Counselling and Psychology

Cancer Diagnosis *

Date of Diagnosis

DD / MM / YYYY

Surgeon

Medical Oncologist

Radiation Oncologist

Other Medical History

Reason for Referral

Is the person being referred a cancer patient?

Yes

No

Please indicate relationship to client

Please upload any relevant clinical information, and include stage/histology where possible

Volunteer Driving

Date of first appointment
(if known)

DD / MM / YYYY

*We need at least 5 working days notice

Time

HH : MM AM/PM

Location of Appointment

Auckland City Hospital

Other

Appointment Schedule

Number of weeks

Estimate Finish Date

DD / MM / YYYY

Estimated duration of appointments

Less than 1 hour

1-2 hours

2-4 hours

More than 4 hours

Mobility *

Fully mobile

Not fully mobile