Patient Referral Form - NZ Familial Gastrointestinal Cancer Service

Mandatory fields are marked *
Referrer Details
Referrer Name *
Referrer Role *
Referrer Address *
District/GP Practice *
Patient Details
NHI *
^([a-zA-Z]{3})([0-9]{4})$
Patient First Name *
Middle Name
Surname *
Preferred name / goes by
Maiden Name
Date of birth *
Month - Day - Year
Ethnicity
Iwi Affiliation if known
Phone Number *
Email
Patient Address *
Post Code
City/Town
Referral Details
If referring for colorectal cancer, does the patient meet the criteria for Category 3 individuals with a potentially high risk of colorectal cancer, as outlined in the grid on the “Health Professionals” page?
Category 3 High Risk

Yes
No
Reason for referral *
Relevant cancer/polyp history/previous endoscopy information (please include ages at diagnoses)*
Family history of cancer and/or gastrointestinal polyps (please include ages at diagnoses)
Maternal
Paternal
If the patient (or a first degree relative) has received genetic testing please provide details:

Please ensure to complete all necessary fields.

Blank	Testing provided for (Name, Relationship to patient)	Date done	Gene name (if known)	Results	Genetics Health Service
1
2
3

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Process
Status
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Submitting this form implies consent from the patient to pass on their details and to be contacted by the New Zealand Familial Gastrointestinal Cancer Service.

Referrer Details