New Zealand Gazette – 2002 – No. 40

Page 1141

✨ Healthcare Referral Form



APPENDIX IV

Referral to Well Child Provider and notification to GP

This form is to be sent to the Well Child Provider and the GP in order to fulfil clauses C4.5.4 & C4.5.5

Mother

Family name: ___

Given name/s: ___

Birth Date: / / __

Address: ____

Daytime phone: __

NHI number: ___

Baby Summary

Family name: ___

Given name/s: ___

Birth Date: / / __

Gender: ☐ Male ☐ Female

NHI number: ___

Gestation: ___ Weeks

Significant birth/postnatal event(s) (e.g. apgar score, birth weight): ____

Feeding at time of referral to Well Child Provider

  • ☐ Vitamin K
  • ☐ Guthrie test
  • ☐ Exclusive Breastfeeding
  • ☐ Fully Breastfeeding
  • ☐ Partial Breastfeeding
  • ☐ Artificial feeding

Comment: ___

Alternative Contact: _____

Summary of ongoing needs identified at time of referral (e.g. referral to Family Start, Multiple Birth Society):** _____

Date referral/notification sent to Well Child Provider and GP: / / __

Planned date of discharge from LMC: / / __

Name of LMC Contact details: ___



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Online Sources for this page:

VUW Te Waharoa — PDF NZ Gazette 2002, No 40


Gazette.govt.nz — PDF NZ Gazette 2002, No 40




✨ LLM interpretation of page content

🏥 Standard Terms and Conditions of Access to Maternity Facility (continued from previous page)

🏥 Health & Social Welfare
Maternity, Access Agreement, Healthcare, Practitioner, Facility, Terms and Conditions, Policies, Complaints, Dispute Management, Suspension, Professional Responsibilities

🏥 Referral to Well Child Provider and Notification to GP

🏥 Health & Social Welfare
Well Child Provider, GP Notification, Maternity, Healthcare, Referral, Baby Summary, Feeding, Ongoing Needs