Clinical Referrals (for GP and Specialist use only)

Please note that we are unable to receive clinical referrals directly via EDI. Please use the form below, email us at admin@canopycancercare.co.nz, fax us on (09) 638 7295 or send via the Healthlink or Specialists & Referrals portals.

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* Required fields

Patient referral form

Referrers Name:*

Address:*

Phone:*

Fax:*

Email*

Patient Name:*

DOB:*

NHI:

Residential Address:*

Postal Address (if different from above):

Preferred Phone Number:*

Patient Email:*

New Zealand Resident:*YesNoUnknown

GP Details (if not the referrer):

Insurance:*YesNoUnknown

Provider:

Clinical Summary:*

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Maximum file size 5MB. File extensions: jpg, gif, jpeg, png, pdf, doc, docx, zip.

Select Canopy Cancer Care Clinic location for Patient to attend*