Special Care Referral Form

1
Full Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Year
Month
Day
3
Phone Number* This field is required.Please enter the best number to reach you
Area Code
Phone Number
4
EmailPlease provide an email to send confirmation
example@example.com
5
Residential Arrangement* This field is required.Please select the residential arrangement listed below
Home
Residential Care
Rest Home
6
Address* This field is required.
Street Address
Suburb
City
Suburb
Postal / Zip Code
New Zealand
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Welfare guardian / Next of kin* This field is required.Please provide contact details and best appointment time
Name & relationship to you
Email
Phone
Please Select
Please Select
Morning
Midday
Afternoon
Best appointment time
8
Dental Concern(s)
Poor Oral Hygiene
Pain
Dental Caries
Loose tooth
Gum disease
Select from dropdown list
Other Concerns
9
Referring PractitionerPlease provide name and contact details
Name
Email
Phone
Clinic Name and/or Address
10
Reason for special dental care referral* This field is required.Please tick appropriate box
Special Needs
Cognitive issues
Oncology
Other
11
Special Needsskip if none
Autism
Down Syndrome
Cerebral Palsy
Global Developmental Delay
SPECIAL NEEDS: select from dropdown list
Other
12
Cognitive Issuesskip if none
write your condition here
Speech impairment
Visual impairment
Hearing impairment
PHYSICAL DISABILITY: select from dropdown list
Please Select
Please Select
Yes
No
Wheelchair – able to transfer?
STROKE : Please enter DATE & TYPE
Areas affected
Please Select
Please Select
Early
Moderate
Late Stage
DEMENTIA Stage
Type
13
Cognitive Issues (cont.)skip if none
Please Select
Please Select
Early
Moderate
Late Stage
PARKINSON'S DISEASE: Early/Mod/Late stage
Type
Please Select
Please Select
Ischaemic heart disease
Heart failure
Rheumatic valve disease
Congenital heart disease
CARDIAC CONDITION: select from dropdown list
Other
14
Oncologyskip if none
Type of cancer
Date of diagnosis
Chemotherapy drug types
Date commenced
Number of cycles
Date of next cycle
Date completed
15
Oncology (cont.)skip if none
Radiation treatment: Head and Neck / Other areas
Date commenced
Date completed
Name and contact of Medical Specialist
16
Medications that increase bleeding risks
Warfarin
Aspirin
Rivaroxaban
Dabigatran
Clexane
Clopidogrel
Other
17
Immunosuppressive medications
Prednisolone
Infliximab
Etanercept
Adalimumab
Other
18
Bisphosphonates for Treatment of Osteoporosis/Cancer
Please Select
Please Select
Alendronate
Etidronate
Risedronate
Zoledronate
Other
Name of Drug
Please Select
Please Select
Oral tablet/capsule
IV (Injection)
Method of administration
Date commenced
Number of doses
Date of last dose
19
Other MedicationsPlease attach medication list here or enter the medications in next slide
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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20
Medical History* This field is required.Please write your medical conditions and medications here
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Large
Normal
Small
Ok
Ok
21
Latest hospital visits and discharge summary (Please attach)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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22
Current Care FacilityPlease enter details of the patient's current aged/special care facility
Name of Facility
Person Completing this form
Email
Phone
Should be Empty: