Refer a Patient or Carer

Te reo TBC

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If you are a health care professional looking to refer a patient or carer, please use the form below.

Alternatively, you can call us on 0800 112 775 and talk to a member of our support team if you prefer. We will be in touch as soon as possible to offer support.

I confirm I have obtained the consent of the individual for Gut Cancer Foundation to provide information about their referral back to me as the referring health professional (which may include disclosing further sensitive and health information about the individual).*

I confirm I have obtained the consent of the individual who is being referred to Gut Cancer Foundation to provide their personal information.*

Title*

Your First Name*

Your Last Name*

Your Email Address*

Your Phone Number*

Your Occupation*

Your Occupation Type - Please select for Allied Health Professional

If Allied Health Professional: "Other" selected, please specify

Your Occupation Type - Please select for Nurse

If Nurse: "Other" selected, please specify

Your Occupation Type - Please select for Doctor

If Doctor: "Other" selected, please specify

Your Occupation Type - Please select for Other

If Other: "Other" selected, please specify

Patient/Carer Title*

Patient/Carer First Name*

Patient/Carer Last Name*

Patient/Carer Date of Birth*

Patient/Carer Email Address

Patient/Carer Postcode*

Patient/Carer Phone Number*

Patient/Carer Gender

Who is this request for?*

Cancer type*

If Cancer Type: Other selected, please specify

Year of diagnosis

Country of Birth

Main/preferred language spoken at home

Will an interpreter be required?

Self-identified culture/ethnicity

If applicable, please list any iwi and/or hapū you whakapapa to or identify with

Is there anything else you'd like to add to support this referral?

I consent to receive marketing communication emails containing updates and information from Gut Cancer Foundation. You may contact us to opt out at any time.

I consent to the collection, use, and disclosure of the information I have provided to Gut Cancer Foundation in accordance with the privacy policy at https://www.gutcancer.org.nz/privacy-policy/

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