Wish Planning form | Ambulance Wish South Australia

If you still need to complete a wish request form you can find it here: https://ambulancewishsa.org.au/request-specialist-needs/

More information about the Wish Recipient

Wish Recipient's First and Last Name * *

Wish Recipient: Mobile Number (If communication with them is relevant) *

Wish Recipient: Gender *MaleFemaleOther

Wish Recipient: Language Spoken * *

Wish Recipient: Country of Birth (If known) *

Wish Recipient: Do they identify as an Indigenous Person (If known) *

Wish Recipient: Are they a DVA Client (If known) *

Wish Recipient: Primary Diagnosis *MalignantNon Malignant

Wish Recipient: Specific Diagnosis* *

Wish Recipient: Any special requirements or restrictions regarding Oral food and drink* *

Wish Recipient: Please describe current mobility and transfer requirements *

Wish Recipient: Please describe any existing pressure area/wound care to be aware of for travelling or transfers on the Wish *

Wish Recipient: If inpatient/resident - when was the current admission? *1 week or lessBetween 1 week and 3 weeksMore than 3 weeksNot relevant

Please tick not relevant if this is not relevant

Wish Recipient: any allergies? (if yes please describe) *

Do they have a 7 step plan that states NOT for recuss *YES they have a 7 step plan that states NOT for recussI'm not sureNO they have a 7 step plan that states NOT for recussOther

Holistic Needs

Describe any social/family history that may be relevant for the wish? *

Describe any cultural/spiritual requirements/traditions that may be relevant for the wish? *

Describe any emotional support requirements that may be relevant for the wish? *

Treating Clinical Team Lead

This is usually their Medical Specialist or GP or NP

Treating Clinical Team Lead: What is their role (Medical Specialist, GP, NP, or describe)? *

Treating Clinical Team Lead: First Name? *

Treating Clinical Team Lead: Last Name? *

Treating Clinical Team Lead: Service or Practice Name? *

Treating Clinical Team Lead: Email? *

Treating Clinical Team Lead: Phone? *

Nurse Escort

Who will be on the Wish

Nurse Escort: First Name? *

Nurse Escort: Last Name? *

Nurse Escort Email? *

Nurse Escort Mobile? *

Nurse Escort Polo T-shirt Size? (S, M, L, XL, XXL) *These are worn on the day and returned when the wish finishes - generally the sizes are on the smaller fit size

Person Completing this form

Person Completing this form: First and Last Name* *

Person Completing this form: Your Role* *

Person Completing this form: Email* *

Person Completing this form: Mobile number *

Anything extra we should consider as part of the wish planning?

This form is to be completed after a Wish Request Form has been submitted and APPROVED.