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Self Referral
Self Referral
Summary
Which is the region closest to you?
*
Which is the region closet to you?
Auckland
Which is the region closet to you?
Rotorua
Which is the region closet to you?
Wellington
Which is the region closet to you?
Other
Your Name
First Name
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*
Last Name
*
*
Primary Phone Number
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*
Email
*
*
Your Address
Flat / Unit / Apartment Number
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Address
*
*
Suburb
*
*
City
*
*
ZIP/Postal Code
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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
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Street Address Line 2
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City
*
ZIP/Postal Code
*
Caregiver #1 - Relation To Child
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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 (DD/MM/YYYY)
*
*
Referrer's Last Name
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The ethnicity you identify with...
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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
Tongan/Cook Island
Filipino
Dutch
Fijian Indian
Tongan/Dutch
Cook Island
Referrer's Phone Number
*
Assigned Gender
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Assigned Gender
Male
Assigned Gender
Female
Assigned Gender
Other
Referrer's email address
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Preferred Name and/ or Pronouns
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A brief overview of your symptoms
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Reason for referral
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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
*
