Nelson Marlborough lead maternity carer self-referral form

Which area are you in?

Full name

Preferred name

Date of birth

Address

National Health Index number (if known)

Language you are most comfortable speaking (if not English)

Are you a New Zealand citizen or permanent resident?

Do you have a GP?

Is this your first pēpi?

Do you have any health conditions or medications you are taking that you would like to tell us about?

Have you had a scan during this pregnancy?

Have you had any blood tests in this pregnancy?

Are you taking Folic acid?

Are you taking iodine?

What is the best way to contact you?

Phone number

What is the best time to call you?

Email address

Conditions and treatments