REGISTRATION FORM ARE YOU REGISTERING YOURSELF? * If referring on behalf of someone else, you must have their consent. Yes - I am registering myself No - I am registering on behalf of someone else IF THIS FORM IS FOR SOMEONE ELSE, PLEASE FILL OUT THIS SECTION. IF YOU ARE REGISTERING YOURSELF, MOVE TO THE NEXT SECTION Full Name: Contact Number: Email: Referring organisation: Relation to the Client START HERE IF YOU ARE REGISTERING YOURSELF Client Details: First Name Last Name NHI: (if known) Gender: Date of Birth Street Address City Contact Number: Email Address: Ethnicity: Languages Spoken Translation support required: Yes No Preferred Contact Hours: Early Morning (before 9am) Working Hours (9am - 5pm) After Working Hours (5pm onwards) Next of kin/Emergency Contact First Name Last Name Relationship to client: Next of kin phone number: Next of kin address: What programmes or services are you interested in? * Registration forms for Tamaiti Health Homes or Healthy Lifestyles programme can be found in the drop-down bar on our homepage. Island Breeze Club Tama Toa Club Digital Literacy programme Progressive Homeownership Scheme Island Wealth Community Navigation (Tautoka Hauora and or KaiΔwhina support) Immunisation/Vaccination support Stop-smoking support Mobile Nursing IF YOU TICKED ANY OF THE LAST TWO BOXES, PLEASE PROVIDE THE BELOW Are you pregnant? No Yes Your registered General Practice: Your General Practitioner: Address of your General Practice: Address 1 Address 2 City State/Province Zip/Postal Code Country Please state any health problems/history and or medication our clinical team should be aware of: Do you have any family members registered within any of our services? How did you hear about us? Community Event Friends or Family Social Media Web Search Would you like to subscribe to our e-newsletter to stay updated on the latest happenings within Tangata Atumotu * Yes No Thank you for registering. Our team members will be in contact within 2-3 business days.
