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First name *

Last name *

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Home number

Email

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General practitioner

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By signing, I confirm that I am the person above; the accuracy of this information; my consent for Northland Psychiatry to seek relevant health information including blood test results, medication details, and other documentation deemed necessary by Northland Psychiatry clinicians for your safe and appropriate treatment; and my acknowledgement that Northland Psychiatry staff operate according to New Zealand's Health Information Privacy Code 2020 (https://www.privacy.org.nz/privacy-act-2020/codes-of-practice/hipc2020/).

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