G.p. Referral Form printable pdf download

G.p. Referral Form

Kaitiaki Coordination Service

For G.P. use only

G.P. Referral form

To: 3D Coordination

3D Coordination

Criteria for access to 3D on reverse.

Jan Glover

EDI: kaitiaki

Fax: 5710154

3D Coordinator

Practice:

Name:

Phone:

G.P.Details

Family Name:

First name:

Also known as:

Child details

Country of Birth

NZ Citizen? Yes / No

NZ Resident? Yes / No

Residency Status

NHI:

DOB:

Gender:

Relationship to child:

Family Name:

First Name:

Parent/NOK/Carer

details:

Address:

Day:

Mob:

Phone:

Presenting concerns

and relevant

examination findings:

(vision, hearing)

Past Medical History:

(include relevant

antenatal and

birth details)

Medication/Allergies/

Immunisations:

Relevant

Family/Social History:

Relevant

Developmental

History:

Thank you for completing this form, feedback will be given on the referral pathway. Please send to

Kaitiaki Coordination Service: Fax 571 0154 or Healthlink EDI: kaitiaki.

Date:_____________

G.P. Signature:_____________________________________

3D Coordination

Email:

jan@kaitiakiservices.co.nz

Kaitiaki Coordination Service

Phone:

07 571 0144 xtn702

47 Fraser Street

Fax:

07 571 0154

Tauranga South

Mob:

027 2004 051

TAURANGA 3112

G.p. Referral Form

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