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.

"*" indicates required fields

X/Twitter

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

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

Untitled*

I confirm I am the priority contact for the below patient

Name of Patient*

First Last

Your relationship to the patient*

Priority Contact Name*

First Last

Phone*

Email*

Address*

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*