Kaumātua RegistrationClient / Visitor DetailsName* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Preferred NameAlso known asAddress* Street Address Suburb City Home PhoneWork PhoneMobileEmail* NHIDate of Birth* DD MM YYYYEthnicity*UntitledSelfFriendWhanauDoctor/NurseHospitalStaff MemberReason for VisitHave you any medical conditions that we need to be aware ofEmergency Contact* First Last Relationship to you*Phone*Health DetailsAre you eligible to receive low cost or free health care in NZ?*YesNoRequired services Nutritional Advice / Healthy Eating Home Visits Rauawaawa Newsletter Exercise Programmes (e.g. Gym) Dr/Hospital support & Transport Housing Advocacy/support Swimming Programmes Educational Forums Diabetes Clinics / Support Group Arts & Crafts Programmes Hearing Clinics Do you require urgent support?*If you’ve indicated yes, a staff member will follow-up with you within one working weekYesNoIn submitting this form you agree to abide by the Health and Safety Guidelines of Rauawaawa Kaumatua Charitable Trust* Agree
