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Health Professional referral form

If you are a health professional, please fill in this form for your patient. We collect the details and abide by our privacy statement. Fill in this form if you are doing it for yourself.

Name of person filling in form

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As a health professional are you a:

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If you are a Health Professional what is your Clinic Name?

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Email for person filling in form

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Phone for person filling in form

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Address for person filling in form

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Patient Title

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Patient First Name

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Patient Last Name

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Patient also known as

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Patient Sex

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Patient Date of Birth

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Patient Ethnicity

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Patient NHI if known

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Patient Postal Address

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Patient City/Town

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Patient Post Code

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Patient Full Residential Address (if different from postal address)

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Patient Phone

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Patient Email

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Patient GP Name

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Patient GP Address

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Reason for referral

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My patient has agreed to register with the national hepatitis B monitoring programme managed by the Hepatitis Foundation and, if required, to be referred to a clinical specialist for further assessment. I understand no information about my condition will be released to anyone without my signed consent, except for health professionals involved in carrying out this programme, including GPs, specialists and Ministry of Health representatives responsible for monitoring the programme.

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Medical History

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Current medications or herbal supplements (please list)

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Address

Thank you for referring your patient we will be in touch with yourself and your patient shortly.

Find us

61 Alexander Avenue, Whakatāne 3120
New Zealand

Or mail: PO Box 647, Whakatāne

Tel: 0800 33 20 10
Fax: 07 307 1266

Main sections

Health Professionals

Privacy Statement

THINK YOU ARE AT RISK?
GET IN TOUCH WITH US AT
0800 33 20 10

You can also send us an email at: hepteam@hfnz.nz

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