- KotahiConnect

West Coast Health - Nutrition Service - Nutrition Self Referral Form

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Self-Referral Referring yourself, or your whānau

Service Provider Referral Referring one of your clients.

Referrer Details

Provider Details

First Name

Last Name

Organisation Name

Contact Details

Phone Number

Email Address

Address

Physical Address

Address 1

Address 2

Suburb

City

Post Code

Postal Address is the same as Residential Address

Client Details

Personal Details

First Name

Middle Name(s)

Surname

DOB

NHI

Gender

Ethnicity1

add another

Contact Details

Preferred Phone

Home Phone

Work Phone

Mobile Phone

Other Phone

Email Address

Address

Residential Address

Address 1

Address 2

Suburb

City

Post Code

Postal Address is the same as Residential Address

Referral Details

Nutrition Self Referral Form

West Coast Health Dietitian Services Request Form

You are eligible if you have one or more of the following condition:

What is your reason for requesting our service

Service interested in:

Name (if completing this referral for someone else)

Profession

Contact details

Consent

Consent to dietitians contacting medical centre for further information::

I consent OR I have discussed this with the referee and they have provided consent

Select your Medical Centre

Referral Discovery

How did you hear about our self-referral service? (please tick);:

Social Media Google Search Word of Mouth GP Practice Other (please specify)

Referral heard through other

Disclaimer: If you have an eating disorder or think you might, see your Doctor who can refer you to a service that can best support you. (Tick to acknowledge this disclaimer)

The following conditions do not meet our criteria

*Bowel complaints with no investigations e.g constipation or diarrhea (use Health Info/Health Navigator resources).
*Healthy eating advice & general adult nutrition (use Health Info/Healthify resources).
*Weight loss – Diets don’t work for long term weight loss 95% of the time, so we don’t recommend them. We focus on forming positive habits that improve health for life.
*Clients taking weight loss medications or very low calorie diets such as Optifast.
*Eating Disorders
If you or your client do not meet our criteria, please see the Te Whatu Ora, Te Tai O Poutini criteria.

Health Info Resources

Health Navigator Resources

Notes