Kaumātua RegistrationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Address* Street Address Suburb City NHIACC (if applicable)Gender*MaleFemaleHome PhoneEthnicity*Date of Birth* DD MM YYYYMarital Status*MarriedSingleWidowedNext of Kin / Caregiver First Last Address* Street Address Suburb City Phone*Relationship to kaumatua*Doctor First Last Surgery DetailsCommunication RequirementsAlertsHazards of visiting address, special needsDiagnosis and disability needsRelevant previous historyReason for referralReferred By* First Last Designation*Kaumatua consents to this referral*YesNoResponseUrgentSemi UrgentNon Urgent