Community Dental Service Referral

Child's First Name

Child's Middle Name(s)

Child's Family Name(s)

Also Known As

Male
Female

Street Address (Include suburb and postcode if known)

Home Number

Mobile Number

Other Contact (Name)

Other Contact's Phone

Email Address (Parent/Guardian)

Brother's/Sister's Name/s and Date of Birth
DOB:

Brother's/Sister's Name/s and Date of Birth
DOB:

Brother's/Sister's Name/s and Date of Birth
DOB:

Medical Practice

Current School/Preschool

Is your child eligible to receive free health care in the NZ public health system?

Yes
No
Don't know

For more information on eligibility please visit www.moh.govt.nz/eligibility (this link will open a blank page) or contact 0800 825 583

Ethnicity:
Which ethnic group does this child belong to? Tick the space/s that apply
NZ European
Maori
Samoan
Cook Island Maori
Tongan
Niuean
Chinese
Indian

Other, please state:

Please add any clinical observations or concerns: