Gestational Diabetes Education e-form

Gestational Diabetes Education e-form

WAIKATO PHARMACIES ONLY Other areas are not contracted for this service
NHI*
Patient Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Free type or use calendar date picker
Ethnicity*
Town (Waikato Only) *
Informed consent | Healthify
I understand and agree to participate in a consultation with my Pharmacist. I consent to my pharmacist accessing relevant medical and hospital records to support my health care. I agree that anonymised data may be used to improve the service.
GDM Self-Management Plan (if not provided by LMS)Diabetes Healthy Eating BrochureAdditional Resources
N/ASmoking Cessation EducationTDaP VaccinationFlu Vaccination
WAIKATO Pharmacy Name (choose from list)*
Pharmacist Full Name*

First NameLast Name
Pharmacy Email*
MUST be completed to receive copy of PDF for pharmacy records
I agree that I have explained the consent process to the patient and have conducted a comprehensive consultation utilising MidCPG Gestational Diabetes Consultation Checklist.
Signature*

Clear
Date of Consultation*

DayMonthYear
Free type or use calendar date picker
DOCUMENT VERSION CONTROL: Gestational Diabetes Form V1.0

PT NAME field hidden 15/12 as per Pete Chandler
Should be Empty: