Information you provide will assist in providing the care and treatment for you and your whanau. This information may be made available to health professionals whose services as required. All details are kept secure and confidential.

Personal Details:

Contact Details:

Telephone Details:


Next of Kin:


Consent: Thank you for providing us with your information so that we can offer the right kinds of support to accomplish your goals;
I give my consent and understand that Te Hau Ora O Ngāpuhi may be required to disclose this information to other agencies for the purposes of monitoring the provision of healthcare and continued treatment. I understand that I have the right under the Privacy Act and Health Information Privacy Code to obtain access and to request correction of any of my personal or health information held by Te Hau Ora O Ngāpuhi.