Physio funding application

Personal details

• First name:*
• Last name:*
• Phone:*
• Email:*
• Address:*
• Suburb:*
• City:*
• Postcode:*
Date of Birth*
Gender*
MaleFemaleGender diverse
Ethnicity*
NZ European
NZ Maori
Australian
Cook Island Maori
Fijian
Niuean
Samoan
Tokelauan
Tongan
Pacific Island not further defined (other)
Chinese
Southeast Asian
Asian not further defined (other)
African
Indian
Latin American/Hispanic
Middle Eastern
European not further defined (other)
Other ethnicity
• Please select your DHB:*
  Auckland District Health BoardBay of Plenty District Health BoardCanterbury District Health BoardCapital and Coast District Health BoardCounties Manukau District Health BoardHawkes Bay District Health BoardHutt Valley District Health BoardLakes District Health BoardMid Central District Health BoardNelson Marlborough District Health BoardNorthland District Health BoardSouth Canterbury District Health BoardSouthern District Health BoardTairawhiti District Health BoardTaranaki District Health BoardWaikato District Health BoardWairarapa District Health BoardWaitemata District Health BoardWest Coast District Health BoardWhanganui District Health BoardDHB unknown
Do you have a Pink Ribbon™ Card? (If you already have a Pink Ribbon™ Card, this can also be used for physio upon approval)*
Yes*
No*
Pink Ribbon Card Number:
Card PIN:

Diagnosis and treatment

• Type of breast cancer:*
  Breast cancer*

  Advanced breast cancer (Metastatic breast cancer)*
• Date of breast cancer diagnosis:*
Date of breast surgery:*
• Please select the type of surgery or surgeries you have had:*
  No surgery

  Lumpectomy

  Mastectomy

  Bilateral mastectomy

  Sentinel node biopsy

  Axillary dissection

  Other (please explain)
• If you have selected other surgery type, please let us know about your surgery
• If you’ve had reconstruction please select which type*
  Implant

  TRAM flap

  Lat. Dorsi

  DIEP

  Bilateral reconstruction

  Other (please explain)

  No reconstruction
• If you have selected other reconstruction type, please let us know about your reconstruction
• Please select the treatment or treatments you have had:*
  Hormone therapy

  Chemotherapy

  Radiotherapy

  Biological

  Other (please explain)
• If you selected other treatments, please explain below:

Physiotherapist

Please select your preferred PINC and STEEL physiotherapist

• Therapist Region*
  AucklandBay of PlentyCanterburyHawkes BayManawatuMarlboroughNelsonNorthlandOtagoSouthlandTaranakiWaikatoWellingtonWest Coast
• Please select your preferred BCFNZ approved physio therapist (If there is no therapist in your area, please let us know, as we hope to expand our service)*
  Choose...

Tell us more

• How did you find out about BCFNZ funding for physiotherapy?
  Breast or oncology nurse referralDoctor or Surgeon referralCancer support referralBCFNZ WebsiteFriend or familyBrochureAdvertisementOther
• Additional comments:

• By applying for funding, I agree to the BCFNZ funding Terms and Conditions and Privacy Policy.*
• I agree to the BCFNZ nursing team supplying my information to Swathe.me and the PINC and STEEL clinics, in order to process my funding application.*