Harbour Sport > AF GP Referral

Section 1 - Patient Details (All Fields Compulsory*)

First Name*:	This field is required.
Last Name*:	This field is required.
Gender*:	Male Female Self-describe Prefer not to say
NHI: (if known)
Date of Birth*:	This field is required.
Ethnicity*:	This field is required.
Weight (kg):	Please enter only numbers
Height (cm):	Please enter only numbers
Street Address*:	This field is required.
Suburb*:	This field is required.
City*:	This field is required.
Postcode:
Home Phone:
Email:	Invalid Email address.
Mobile:
Work:

Section 2 - Medical Conditions

BMI:

Patient Medical Conditions

Respiratory conditions
Depression/Anxiety
CVD
High Cholesterol
Heart Conditions
Stroke
Stress
High Blood Pressure
Low Blood Pressure
Weight Loss Support
Arthritis
Injury
Mental Health Conditions
Epilepsy
Joint replacement
Osteoporosis
Asthma
Cognitive Impairment
Pregnant
Smoker
Number of cigarettes per day

Diabetes

Pre-diabetic (HbA1c 41-49mmol)
Gestational Diabetes
Type 2
Type 1

Other relevant medical information (e.g. pregnant or more details about medical conditions above)

File Attachment (Only add if required. If multiple files is needed, please zip into one folder first.)

Section 3 - Referral Information (All Fields Compulsory*)

Referrer Type:	Doctor Nurse Other Health Professional
Health Professional First Name*:	This field is required.
Health Professional Last Name:
Client's Medical Centre Name*:	This field is required.
Client's Medical Centre Email*:	This field is required. Invalid Email address.
My Organization Name*:
My Organisation Email:	Invalid Email address.

By ticking this, I confirm that I have explained the Active Families/Teens process and the patient has consented for their details to be forwarded to HARBOUR SPORT Active Families/Teens who will provide them with support and advice.
This field is required.

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