Stop Smoking Register Te Hā Waitaha Referral Form Date* DD slash MM slash YYYY Referral Type* Self Agency/Professional Whānau/friend/other Referrer DetailsName First Last Organisation or relationship to person being referred Contact Phone Number Email Client DetailsName* First Last Date of Birth* DD slash MM slash YYYY NHI (if known) Gender*MaleFemaleGender DiverseAre you pregnant?YesNoEthnicity* NZ Māori NZ European Samoan Tongan Pacific Island Iwi Phone*When is the best time to call you?* Can we leave you a message? (Click any that apply)* Text Message Voicemail Please don't leave me a message Address Street Address Address Line 2 City ZIP / Postal Code Email Enrolled with a GP?*YesNoUnknownGP DetailsGP Name Practice Name COVID-19 Vaccination StatusYou do not need to be vaccinated to access our services, however, your vaccination status may affect the way our services are delivered (e.g. numbers for group programmes etc).Please select one of the following options: I am fully vaccinated I am partially vaccinated I am not vaccinated Not sure / Prefer not to answer Comments (optional)CAPTCHA
