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 *
Contact Number *
Email Address *