Home - Send A Referral Send A Referral Step 1 of 4 25% Client DetailsThe client is the person you are making the referral for.NHI Number Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name(Required) First Last Address Street Address Address Line 2 Town/City Postal Code Phone(Required)Email Ethnicity Care Partner DetailsThe care partner is the primary support person for the client. This might be a spouse, family/whānau, friend etc.Name(Required) First Last Relationship To Client(Required) Address Same as client Street Address Address Line 2 Town/City Postal Code Phone(Required)Email Who should Dementia Waikato contact in the first instance?(Required) Client Care Partner Other Medical InformationDiagnosis(Required) Date DiagnosedDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Diagnosing Clinician GP/Practice Name Does the client live alone? Yes No Does the client have an Enduring Power of Attorney (EPOA) Yes No Has it been activated? Yes No EPOA Name First Last EPOA Phone Referral DetailsReason for referral(Required)Referrer Name(Required) First Last Referrer Role(Required) e.g. Self, Family, FriendReferrer Service e.g. Church, LawyerReferrer PhoneReferrer Email Is the clients vaccination status up to date?Please note this will not affect your ability to access our services, or the level of service we provide, it is for planning purposes and helps to keep all of our clients safe. Yes No Don't know Consent(Required) I confirm the client (Person with Dementia, Care Partner or EPOA) consensts for referral.NameThis field is for validation purposes and should be left unchanged. Δ
