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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
Which is the region closet to you?
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
*
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...
Asian
Māori
NZ European
Other
Pacific Peoples
Referrer's Phone Number
*
Assigned Gender
Assigned Gender
Male
Assigned Gender
Female
Assigned Gender
Other
Assigned Gender
Do not want to say
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
ACO education session
Reason for referral
Spirometry
Reason for referral
Other advice
Current medications and other relevant information
*
GP/Surgery name and address
*
