You’re offline. This is a read only version of the page.
Skip to main content
Custom Portal
Custom Portal
Toggle navigation
Contact Us
Sample Pages
Sample Pages
Page
Full Page with Child Links
Full Page without Child Links
Blank Page
Category
Page with Side Navigation
Page with Side Navigation and Sidebar
Search
Sign in
Home
Self Referral
Self Referral
Summary
What is the location of the person you are referring?
Which is the region closet to you?
Auckland Central
Which is the region closet to you?
Waitemata
Which is the region closet to you?
Wellington
Your Name
First Name
Last Name
Primary Phone Number
Email
Topic
Your Address
Flat / Unit / Apartment Number
Address
Suburb
City
ZIP/Postal Code
Contact
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 - 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 (eg 24/AUG/2022)
Referrer's Last Name
The ethnicity you identify with...
Vietnamese
Sri Lanken
Tongan/Samoan
NZ European
Maori
Cook Islands Maori
Samoan
Tongan
Niuean
Tokelauan
Fijian
Tuvaluan
Other Pacific Peoples
Other European
Southeast Asian
Chinese
Indian
Other Asia
Middle Eastern
Latin American
African
Other Ethnicity
Don't Know
Syrian
NZ European/Maori
Other
Pacific
Asian
South African
Chilean
Scottish
Maori/Samoan
Indian/Tongan/Samoan
Tongan/Cook Island
Filipino
Dutch
Fijian Indian
Tongan/Dutch
Cook Island
Referrer's Phone Number
Assigned Gender
Assigned Gender
Male
Assigned Gender
Female
Assigned Gender
Other
Referrer's email address
Preferred Name and/ or Pronouns
A brief overview of your symptoms
Reason for referral
Reason for referral
Asthma education session
Reason for referral
COPD education session
Reason for referral
Spirometry
Reason for referral
Other advice
Current medications and other relevant information
GP/Surgery name and address
