Referral FormFill out this form if you are a referring Health Professional Your information Referrers Name * First Name Last Name Referrers role * Name of organisation/practice * Email * Phone * (###) ### #### Would you like to receive an e-newsletter with information, research and tips on healthy lifestyles? * Yes please No thanks Please fill the information below for the individual you are referring Patient Name * First Name Last Name Date of birth * Please enter as dd/mm/yyyy Gender * Please select an option below Female Male Gender diverse I prefer not to say Pronouns He/Him She/Her They/Them Other Ethnicity * New Zealand Māori New Zealand European Other European Samoan Cook Island Māori Tongan Niuean Tokelauan Fijian Asian Pacific Peoples Asian Southeast Asian Chinese Indian Other Asian Middle Eastern Latin Amercian African I prefer not to say I don't know Other Iwi Secondary Iwi NHI Number Physical address * Please include street, suburb and post code Phone * Email * Enter N/A if email address is unknown Medical Centre * Name of GP * Health Conditions * High blood pressure High cholesterol Prediabetes Type 2 diabetes Depression Anxiety None of the above Are there any factors that may affect participation in class? E.g. use a walker, low vision etc. Please list any special dietary requirements or food allergies e.g. gluten free, vegetarian, etc Reason for referral / Comments Thank you!
