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Patient Information Form

This form helps us gather important details about you and your primary points of contact.

All information you provide on this form is kept confidential.

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This field is for validation purposes and should be left unchanged.
Patient Information
Name*
First Last Preferred Name
Title
- Mr
- Mrs
- Ms
- Miss
Pronouns
Address*
Street Address Suburb City Postcode
Primary Phone Number*
Alternative Contact Number

Background / Culture
Country of Birth*
NZ Citizen*
- Yes
- No
NZ Residency*
- Yes
- No
Preferred Language*
Interpreter required*
- Yes
- No
Ethnicity
Iwi / Hapu (optional)
Do you have any cultural, religious, faith or spiritual belief you would like us to be aware of?*
- Yes
- No
Please tell us a bit more about that if you wish.
Occupation (or past occupation)
Who do you currently live with?*

Service providers
GP Name*
Practice*
Your current pharmacy*
Please list any other agencies involved in your care (e.g. District Nursing, Cancer Society, Specialists etc)
Please tell us about any allergies you have
Do you have a St. John's Membership?*
- Yes
- No
Do you have a medical alarm (pendant or bracelet)?*
- Yes
- No
- I would like more information regarding medical alarms
Do you have an Advanced Care Plan in place?*
- Yes
- No
- I would like more information regarding an Advance Care Plan
Do you have an Enduring Power of Attorney (EPOA)?*
Please note: For us to act upon this we will need to have a copy on file. Property EPOA is not required.
- Yes
- No
EPOA Name
First Last
EPOA relationship to patient

Priority Contact ONE
Priority Contact ONE*
First Last
Can we share your information with this person?*
- Yes
- No
Relationship to patient*
Phone*
Email
Address*
Street Address Address Line 2 City ZIP / Postal Code Country

Priority Contact TWO
Priority Contact TWO
First Last
Can we share your information with this person?
- Yes
- No
Relationship to patient
Phone
Email

Priority Contact THREE
Priority Contact THREE
First Last
Can we share your information with this person?
- Yes
- No
Relationship to patient
Phone
Email

Priority Contact FOUR
Priority Contact FOUR
First Last
Can we share your information with this person?
- Yes
- No
Relationship to patient
Phone
Email

Physical Address:
43 Te Puna Station Road, RD6, Tauranga 3176
Postal Address:
PO Box 16299, Bethlehem, Tauranga 3147

Contact:
+ 64 7 552 4380

For patient-related queries please email
info@waipunahospice.org.nz

For non-patient related queries please email
supporter@waipunahospice.org.nz

Your Care
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Health Professionals
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