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Brought to you by Health New Zealand | Te Whatu Ora – Southern and WellSouth primary health network

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  • Current Patient information
  • Health Record
  • Information Requested
  • For official use
  • Child under 16 years of age (legal guardian consent)
  • Consent by patient administration/representative to access information
  • Authorisation to disclose personal information to a third party
  • 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.