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Self referral and enrolment form

Fill in this form for yourself, or this one if you are a health professional for your patient. We collect the details and abide by our privacy statement.

I am filling this out for:

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Name of Person filling in form

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Patient Title

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Patient First Name

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Patient Last Name

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Also Known As

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Sex

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Date of Birth

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Ethnicity

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NHI if known

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Postal Address

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City/Town

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Post Code

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Full Residential Address (if different from postal address)

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Phone

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Email

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GP Name

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GP Address

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Reason for referral

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I agree to register with the national hepatitis B monitoring programme managed by the Hepatitis Foundation and, if required, to be referred to a clinical specialist for further assessment. I understand no information about my condition will be released to anyone without my signed consent, except for health professionals involved in carrying out this programme, including GPs, specialists and Ministry of Health representatives responsible for monitoring the programme.

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Medical History

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Current medications or herbal supplements (please list)

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Address

Thank you for sharing your details. We will be in touch soon.

Find us

61 Alexander Avenue, Whakatāne 3120
New Zealand

Or mail: PO Box 647, Whakatāne

Tel: 0800 33 20 10
Fax: 07 307 1266

Main sections

Health Professionals

Privacy Statement

THINK YOU ARE AT RISK?
GET IN TOUCH WITH US AT
0800 33 20 10

You can also send us an email at: hepteam@hfnz.nz

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