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Brought to you by Te Whatu Ora - Southern and WellSouth primary health network

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  • 1 Current: Patient information
  • 2 Health Record
  • 3 Information Requested
  • 4 For official use
  • 5 Child under 16 years of age (legal guardian consent)
  • 6 Consent by patient administration/representative to access information
  • 7 Authorisation to disclose personal information to a third party
  • 8 Complete

This form should be ONLY used if you are a patient or family member requesting information. 

All other requests should be directed to the appropriate service.