Gestational Diabetes - Waikato Only
Pharmacy Information
Claimant Number:
*
Community Pharmacy Name
Dispensary Email
City
District
Patient Information
NHI
*
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Free type or use calendar date picker
Ethnicity
*
Please Select
Māori
NZ European
Pasifika
Chinese
Indian
Other
Residing Town (Waikato Only)
*
Informed consent | Healthify
Patient Consent
*
Patient/Caregiver understands and agrees to participate in this service and consents for the pharmacist to access relevant medical records and share relevant information with other healthcare providers. They agree that anonymised data may be used to improve this service.
Consultation Data
Provided to Patient
*
GDM Self-Management Plan (if not provided by LMS)
Diabetes Healthy Eating Brochure
Additional Resources
Booked Patient for additional services:
N/A
Smoking Cessation Education
TDaP Vaccination
Flu Vaccination
Additional Clinical Notes (Voluntary)
Free text field for your note taking
Pharmacist Declaration
Date of Consultation
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Free type or use calendar date picker
Pharmacist Declaration:
*
I agree that I have explained the consent process to the patient and have conducted a comprehensive consultation utilising "MidCPG Gestational Diabetes Consultation Checklist".
Pharmacist Full Name
*
First Name
Last Name
Pharmacist: Please check all fields are accurate before submitting. A report will be emailed to your dispensary email.
Print
Submit
Signature - ARCHIVE
Should be Empty: