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0800 HE WAKA (439 252)

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  • 0800 439252
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Referral Form

To refer whiaora to He Waka Tapu please complete
the below form

Please Note:

If you wish to complete a self-referral you must do so in person at He Waka Tapu.

Please call if you have any questions: 0800 HE WAKA (439 252)

Referrer Information

Referrer organisation required
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Referrer phone required
Referrer email required

Client Details

Client first name required
Client last name required
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Gender required
Ethnicity required
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Client address required
Client contact number required
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Preferred contact method required
Medical Practice / GP required

Next of Kin

Next of kin name required
Next of kin relationship required
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Reason for referral required
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