Priority Contact Consent Form | Waipuna Hospice, Te Puna, Tauranga

This form collects your consent to be the priority contact for a patient and your current and future contact preferences.

All information you provide on this form is kept confidential.

This field is for validation purposes and should be left unchanged.

To be completed by the priority contact of the patient only.

Untitled(Required)

I confirm I am the priority contact for the below patient

Name of Patient(Required)

First Last

Your relationship to the patient(Required)

Priority Contact Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Suburb City Postcode

I want to opt-out from receiving information on follow up care for family/whānau.

Opt-out

I want to opt-out from receiving information on events, fundraising and newsletters.

Opt-out

Signature(Required)