Gestational Diabetes Education e-form

Gestational Diabetes Education e-form (WAIKATO ONLY)
Patient Information
NHI*
Date of Birth*

DayMonthYear
Free type or use calendar date picker
Ethnicity*
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 BrochureAdditional Resources
Booked Patient for additional services:

N/ASmoking Cessation EducationTDaP VaccinationFlu Vaccination
Additional Clinical Notes (Voluntary)
Free text field for your note taking
Pharmacist Declaration
WAIKATO Pharmacy Name (choose from list)*
Pharmacist Full Name*

First NameLast Name
Pharmacy Dispensary Email*
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".
Signature*

Clear
Date of Consultation*

DayMonthYear
Free type or use calendar date picker
Pharmacist: Please check all fields are accurate before submitting. A report will be emailed to your dispensary email.
Patient Full Name (REMOVE via PETE 15/12/2025)*

First NameLast Name
Should be Empty:

Gestational Diabetes Education e-form (WAIKATO ONLY)