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 Additional InformationComments (Optional)CAPTCHA
