CLIENT REFERRAL FORM HOSPICE MID CANTERBURY – CLIENT REFERRAL FORM–None–AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia & HerzegovinaBotswanaBrazilBritish Indian Ocean TerBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCayman IslandsCentral African RepublicChadChannel IslandsChileChinaChristmas IslandCocos IslandColombiaComorosCongoCook IslandsCosta RicaCote DIvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerGabonGambiaGeorgiaGermanyGhanaGibraltarGreat BritainGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuyanaHaitiHawaiiHondurasHong KongHungaryIcelandIndonesiaIndiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalaysiaMalawiMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMidway IslandsMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNambiaNauruNepalNetherland AntillesNetherlands (Holland, Europe)NevisNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorwayOmanPakistanPalau IslandPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarRepublic of MontenegroRepublic of SerbiaReunionRomaniaRussiaRwandaSt BarthelemySt EustatiusSt HelenaSt Kitts-NevisSt LuciaSt MaartenSt Pierre & MiquelonSt Vincent & GrenadinesSaipanSamoaSamoa AmericanSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTahitiTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IsTuvaluUgandaUnited KingdomUkraineUnited Arab EmiratesUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuelaVietnamVirgin Islands (Brit)Virgin Islands (USA)Wake IslandWallis & Futuna IsYemenZaireZambiaZimbabwe Ethnic Origin1 – European11 – New Zealand European128 – Australian2 – Māori3 – Pacific Peoples4 – Asian42 – Chinese43 – Indian5 – Middle Eastern/Latin American/African53 – African6 – Other Ethnicity99 – Not Stated Other agencies currently involved (for example, Palliative Care Team, District Nurses, Dementia Canterbury, Cancer Society, ComCare, PSUSI) or services already being provided.The client is aware of and consented to referral to Hospice Mid Canterbury *–None–YesNo“The client is aware of and has consented to referral to Hospice Mid Canterbury”
