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Waipuna Hospice – Life is Special
Waipuna Hospice provides specialist medical services, nursing care and support to people living with an illness for which cure is no longer an option. We care for patients and their families living in Tauranga and the Western Bay of Plenty.
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Home
About Waipuna Hospice
Our History
Our View On Assisted Dying And End of Life
Support Us
Wills Month 2024
Shining Stars
Donate
Regular Giving
Buy Our Products
Merchandise Combo
2025 Diary
2025 Calendar
Light of Light Beeswax Candle
Donate Goods
Volunteer
Waipuna Hospice Charity Shops
Share Your Story
Donate an Occasion
Waipuna for Tomorrow Bequest Programme
Membership
Our Promise to You
Our Supporters
Your Care
Hospice at Home
Inpatient Care
Patient and Family Support
Professionals
Referral to Waipuna Hospice
Education
Work with Us
News
News and Stories
Newsletter
Journal for the new “normal.”
Facebook
Instagram
Photograph and Video Disclaimer
FAQ
Contact Us
Donate
Referral
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Referral
Referral
Urgency
*
Urgent (1-2 Working Days)
Routine (2-4 Working Days)
Patient Consent to Referral
*
(Please note, consent is required prior to referral)
Yes
No
Patients Details
Name
*
First
Last
NHI Number
*
Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Gender
Male
Female
Other
Ethnicity
*
Date of Birth
*
DD slash MM slash YYYY
NZ Citizen/Resident
*
Yes
No
Preferred Language
*
GP Details
GP Name
*
Practice
*
Next of Kin (NOK)
NOK Name
*
First
Last
NOK Email
NOK Phone
*
What are this patient's specialist palliative care needs?
Physical Symptons
*
None
Potential
Significant
Social Needs
*
None
Potential
Significant
Psychological/Emotional
*
None
Potential
Significant
Cultural/Spiritual
*
None
Potential
Significant
Details
*
Primary disease process
Co-morbidities
Social Situation
*
Lives alone
Lives with others, no support provided
Lives with others who provide support
Receives external support
Other
Other explained…
*
Mobility
*
Ambulant independently
Ambutant with aids
Bedbound
Other
Other explained…
*
Known Allergies or Alerts
*
(including infectious status/ICD/pacemaker/community safety risks)
Other services involved
Medical Oncology
Radiation Oncology
Cancer Society
Cardiac
Respiratory
OT/Physio
Social Work
Iwi provider
District Nursing
Mental Health Services
Support Net
Short Term Services
Speech Language Therapy
ACC
Other
Other explained…
*
Please Attach Required Documentation
Referrals cannot be processed without this information
Medications List
Drop files here or
Select files
Max. file size: 100 MB.
Hospital Discharge Summary
Drop files here or
Select files
Max. file size: 100 MB.
Recent Clinic Letters/GP Notes
Drop files here or
Select files
Max. file size: 100 MB.
Referred by
Referrer Name
*
First
Last
Organisation
Designation
Email
*
Phone
*
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