Active Families Refer Yourself

ACTIVE FAMILIES/TEENS REFERRAL FORM- WEST AUCKLAND, NORTH SHORE AND RODNEY
1. Please note all fields are compulsory
2. An Active Families Healthy Lifestyle Advisor will be in touch within 10 working days of receiving the referral
3. Contact Harbour Sport if you have any questions on 09 415 4657

---

Section 1 – Patient Details (All Fields Compulsory*)

First Name * :
Last Name * :
Gender * :	MaleFemale
Date of Birth * :
Ethnicity * :
Weight (if known):
Height (if known):
Street Address * :
Suburb * :
Postcode * :
Phone * :	Home PhoneMobile PhoneWork Phone

---

Section 2 – Medical Conditions (All Fields Compulsory*)

Patient Medical Conditions (Please list all medical conditions, including weight issues/mental illness) * :

Diabetes * :
Pre-diabetic (HbA1c 41-49mmol)T1T2Not Applicable
Other relevant information * :

File Attachment (Only add if required. If multiple files is needed, please zip into one folder first.)

---

Section 3 – Referrer Information

Self-Referral (Please tick box):	Yes
Name * :
Relationship to Child * :
GP/Nurse (if known) * :
Phone * :
Extn * :
Medical Centre * :
Postal Address (if known):
Date * :

---

Harbour Sport will provide you with support and advice.

---