Self Management Education Programme
Self-Referral Form
Select the General Practice Clinic you are enrolled with
*
Please Select
Beachlands Medical Centre
Botany Junction Medical Centre
Botany Terrace Medical Centre
Crawford Medical Centre
Clevedon Medical Centre
Eastern Family Doctors
Howick House Medical Centre
Highbrook Medical
Highland Park Medical Centre
Juliet Ave Surgery
Kawakawa Bay Orere Health Clinic
Marina Medical
Millhouse Integrative Medical Centre
Ormiston Medical Centre
Pakuranga Medical Centre
Picton Surgery
Pukekohe Family Health Care
Vincent Street Family Doctors
Doctors Name
*
What programme/s would you like to attend?
*
Mindfulness Based Stress Reduction (8-week programme)
Diabetes Self Management (4-week programme)
Your Name
*
First Name
Last Name
Email Address
*
example@example.com
Date of Birth
*
-
Day
-
Month
Year
Gender
*
Male
Female
Gender Diverse
Contact Number
*
mobile number preferred
Address
*
Street Address
Street Address Line 2
Suburb
State / Province
Postal / Zip Code
National Health Index (NHI) Number (if known)
How did you find out about our programmes?
*
GP/Nurse/Clinic Staff
East Health Website
Friend/Family/Colleague
Social Media
Other (e.g. pharmacist, physiotherapist, psychologist)
Terms and Conditions
By submitting this self referral form, I consent to being contacted by the team at East Health to participate in the selected Self Management programme/s. I also consent to my GP clinic being notified of my attendance, unless I advise the organiser otherwise.
Submit
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