3D Coordination
G.P. Referral form
For G.P. use only
To: 3D Coordination
3D Coordination Practice:
Name:
Family Name:
First name:
Country of Birth
NZ Citizen?
NHI:
DOB:
Family Name:
First Name:
G.P. Details Also known as:
Child details Residency Status
Parent/NOK/ Carer details:
NZ Resident? Gender: Relationship to child:
Address:
Phone: Email Name School/EEC Presenting concerns and relevant examination findings: (vision, hearing) Past Medical History: (include relevant antenatal and birth details)
Mob:
Parent agrees to 3D emailing questionnaires to school?
Medication Allergies Immunisations:
Relevant Family History Social History:
Relevant Developmental History: Feedback will be given on the referral pathway. Please send to 3D Coordination: Healthlink EDI: kaitiaki Email 3D@kaitiakiservices.co.nz Fax 571 0154
Date:_______________ 3D Coordination Kaitiaki Services 47 Fraser Street Tauranga South TAURANGA 3112
G.P. Signature:_________________________________________________________ Email: Phone: Fax: Mob:
3D@kaitiakiservices.co.nz 07 571 0144 07 571 0154 027 207 1914