Take the First Step: Join Our 5 Week Quit Smoking Challenge Today!

First name

Last name

Gender

Male

Female

Email

Phone:

Phone Work:

Address

Date of Birth: DD/MM/YYYY

NHI: (if known)

What ethnic group do you belong to:

Which Iwi group do you belong to:

GP Practice:

GP Address

Do you smoke?

Tailor Made Cigarettes

Loose Tobacco / Rollies

Do you have transport

Yes

No

Contact Person Details/Next of Kin

Name:

Relationship:

Phone (work):

Phone (home):

Cell Phone:

Residential Status:

Country of Birth:

Are you a New Zealand resident:

Yes

No

Are you a refugee:

Yes

No

Are you on a working visa:

Yes

No

How many do you smoke per day?

Who would you like as your coach

Authorisation and Consent: The main purpose for collecting this information is to assist in your care and treatment, but there are other related purposes, such as assisting with the administrative aspects of your care and monitoring the quality of patient care, treatment, and health outcomes of our patients. You should note that:

- All personal information collected during your treatment will be filed as part of a medical file and is subject to the provisions of the Health Information Privacy Code, 2020.

- You have the right to access this information and to request changes to personal details.

- Information may be conveyed to other health practitioners in the interest of your treatment.

- Some information collected about you will be forwarded to the Ministry of Health or its agent and to the New Zealand Health Information Service.

- Some information may be used for statistical purposes that will not identify you.

- Under the Privacy Act 2020, Turanga Health requires your permission to collect and hold information about your participation in the services offered by this organisation.

Waiver: I accept that participating in Turanga Health programmes may contain a level of danger and that accidents can occur that may result in serious injury and/or death and/or property damage. I understand that participation is entirely at my own risk. I also understand that I should not participate in this programme unless my physical condition enables me to complete the programme. I indemnify Turanga Health against all liability arising out of my participation in the programme, loss of personal equipment, and/or damage to third-party property that may result from my involvement. I consent to receive any medical treatment that the organisation may deem desirable during or after the programme. I understand that road rules apply at all times and that all roads are open for public use.

I agree and accept the Waiver

Signature