Patient referral form

Healthcare Professionals – Patient referral form

If you are a healthcare professional and wish to refer a patient, please complete the below form. We will acknowledge your referral within the next working day and contact the patient.

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HealthLink ID: TURLEYME

Phone: 0800 226 784

Email: hello@thewomensclinic.co.nz

Your details

Has the patient had a blood test? *

Yes

No

Do you have the results of the patient’s blood test?

Yes

No

Upload blood test results:

Upload

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Has the patient had an ultrasound scan? *

Yes

No

Do you have the results of the ultrasound scan?

Yes

No

Upload scan results:

Upload

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fileuploaded.jpg

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Patient details:

Safe contact details:

Is it safe to call? *

Yes

No

Is it safe to text?

Yes

No

Is it safe to leave a voice message? *

Yes

No

Is it safe to email?

Yes

No

Do you require a discharge summary? *

Yes

No

Thank you! Your submission has been received!

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Alternatively, call us

And talk to one of our administrators and they can walk you through what’s expected and making an appointment.

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Healthcare Professionals – Patient referral form

Your details

Patient details:

Safe contact details:

Alternatively, call us

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