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Patient Referral
Patient Referral
Location
What location does the patient reside in?
Auckland Central
Waitemata
Wellington
Telehealth
Modified On
Address 1: Address Type
Default Value
Address 1
Address line 1
Address line 2
Address line 3
City
State/Province
ZIP/Postal code
Country/Region
Country/Region
*
Patients Name
First Name
*
Last Name
*
Primary Phone Number
*
Email
*
*
Patient Address
Flat / Unit / Apartment Number
*
Address
*
Suburb
*
City
*
ZIP/Postal Code
*
Patient is a Child
Yes
No
Is this a self-referral?
Is this a self-referral?
Patient Referral
Is this a self-referral?
Self Referral
Caregiver#1
First Name
*
Last Name
*
Address: Street Address
*
Street Address Line 2
*
City
*
ZIP/Postal Code
*
Caregiver #1 - Phone
*
Caregiver #1 - Email
*
Caregiver #1 - Relation To Child
*
Caregiver#2
First Name
*
Last Name
*
Address: Street Address
*
Street Address Line 2
*
City
*
ZIP/Postal Code
*
Caregiver #2 - Relation To Child
*
NHI Number
*
Referrer's First Name
*
Date of Birth (e.g. 29/AUG/2022)
*
Referrer's Last Name
*
Ethnicity selected on website
*
Referrer's Phone Number
*
The ethnicity they identify with...
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Referrer's Email Address
*
Assigned Gender
Male
Female
Other
Do not want to say
Referrer Role
*
Preferred Name and/ or Pronouns
*
Patient Diagnosis
*
Reason for referral
Asthma education session
COPD education session
ACO education session
Spirometry
Other advice
Current medications and other relevant information
*
GP/ Surgery Name and Address
*
Verbal informed consent for referral obtained
General referral comments
*
