Referral Form

 

Rainbow Place Online Referral Form

This form will submit a request to our Rainbow Place nurses. If your request is urgent (requiring a response within 24 hours) please call us on 07 859 1260 (press 1 to speak to a nurse if calling after-hours).

Please indicated the urgency of your referral
 
 

Patient Details

NHI Number *
 
Surname *
 
First Name *
 
Date of Birth *
 
Gender *
 
Ethnicity/Iwi *
 
First Language
 
Address *
Email Address *
 
 

Referral Information

Primary Diagnosis *
 
Other significant health conditions *
Reason for Referral
Medical/nursing needs
Social/psychological/spiritual needs
 

Medical Team Details

Name of GP
 
Practice Name and Address *
Contact Number *
 
Email Address *
 
Name of Lead Paediatrician *
 
Hospital/DHB *
Contact Number *
 
Email Address
 
 

Details of Family/Carers

Name *
 
Relationship *
 
Contact Number *
 
Is there an existing Power of Attorney for Health and Welfare? *
 
If yes, please provide name and contact details
 

Referrer Details

Name *
 
Organisation *
 
Position
 
Department
 
Contact Number *
 
Email Address *