West Coast PHO Dietitian Services Request Form Name (of person being referred) * Address * Email address (if you have one) Phone number * Date of birth * GP/Medical Centre * You are eligible if you have one or more of the following condition: - None -PrediabetesHigh cholesterolHigh blood pressureSleep apnoea Polycystic ovarian syndrome Non-alcoholic fatty liverType 2 diabetesCardiovascular diseaseFamiies/Whanau and youth referred by Registered Health Professional to improve health behavioursNutrition concerns; yo-yo dieting / habits causing distress AND ready to focus on healthy habits not weight loss goals What is your reason for requesting our service * Service interested in * One-on-one dietitian clinic appointment Melon (online wellness programme) Living Well with Diabetes course Don't know Name (if completing this referral for someone else) Profession Contact details * Consent to dietitians contacting medical centre for further information * I consent OR I have discussed this with the referee and they have provided consent How did you hear about our self-referral service? (please tick); * Social media Google search Word of mouth GP Practice Other (please specify) _________________________________________________ Disclaimer: If you have an eating disorder or think you might, see your Doctor who can refer you to a service that can best support you. * Tick to acknowledge the above disclaimer Exclusion Criteria * Bowel_compIaints_with_no_investigation_e.g_constipation_or_diarrhoea(use_Health_Info/_Health_Navigator_resource)|Bowel complaints with no investigations e.g constipation or diarrhoea (use Health Info/Health Navigator resources) * Healthy eating advice & general adult nutrition (use Health Info/Health Navigator resources) * Weight reduction *Clients taking weight loss medications or very low calorie diets such as Optifaast Eating disorders If you or your client do not meet our criteria, please see the Te Whatu Ora, Te Tai O Poutini criteria, click here
