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Your guide to a medical abortion
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What to expect after
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Your guide to a surgical abortion
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What to expect after
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Your guide to IUDs
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Your guide to the pill
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Abortion cost overview
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Patient referral
HealthLink ID: TURLEYME
0800 226 784
hello@thewomensclinic.co.nz
Healthcare Professionals – Patient referral form
If you are a healthcare professional and wish to refer a patient, please complete the below form. We will acknowledge your referral within the next working day and contact the patient.
Comments
This field is for validation purposes and should be left unchanged.
Your details
Your first name
(Required)
Untitled
Email
I am a*
(Required)
I am a*
DECIDE Nurse
Doctor
Family Planning Nurse
Healthline Nurse
Midwife
Nurse
Te Whatu Ora region*
(Required)
Te Whatu Ora region*
Northland
Auckland
Waikato
Bay of Plenty
Gisborne
Hawke’s Bay
Taranaki
Manawatū-Whanganui
Wellington
Tasman
Nelson
Marlborough
West Coast
Canterbury
Otago
Southland
I am referring the patient for a
I am referring the patient for a
Telemed Medical Abortion
In Clinic Medical Abortion
Surgical Abortion
Contraception
Other
Date of patient's last period start? Write 'not sure' if unsure
Has the patient had a blood test? *
(Required)
Has the patient had a blood test? *
Yes
No
Where was the blood test ordered?
Do you have the results of the patient’s blood test?
Do you have the results of the patient’s blood test?
Yes
No
Upload blood test results:
Upload blood test results:
Max. file size: 100 MB.
Has the patient had an ultrasound scan? *
(Required)
Has the patient had an ultrasound scan? *
Yes
No
Where was the scan ordered?
Do you have the results of the ultrasound scan?
Do you have the results of the ultrasound scan?
Yes
No
Upload blood test results:
Upload blood test results:
Max. file size: 100 MB.
Patient details:
Patient’s first name*
(Required)
Patient’s last name*
(Required)
Patient’s date of birth* i.e. DD/MM/YYYY
(Required)
Untitled
(Required)
Patient's Gender*
Female
Male
Non-binary
Other
Prefer not to answer
Patient’s address
Patient’s NHI number
Patients GP Practice name
Patients name of GP
Safe contact details:
Phone number*
(Required)
Is it safe to call? *
(Required)
Is it safe to call? *
Yes
No
Is it safe to text?
(Required)
Is it safe to text?
Yes
No
Is it safe to leave a voice message? *
(Required)
Is it safe to leave a voice message? *
Yes
No
Email address
Is it safe to email?
Is it safe to email?
Yes
No
Do you require a discharge summary? *
(Required)
Do you require a discharge summary? *
Yes
No
Does the patient have a Community Services Card?*
(Required)
Does the patient have a Community Services Card?*
Yes
No
Card number
Expiry date
DD slash MM slash YYYY
Message
CAPTCHA
Close Menu
Abortion Options
Early medical abortion
Your guide to a medical abortion
Taking the pills
What to expect after
Aftercare
Surgical abortion
Your guide to a surgical abortion
The procedure
What to expect after
Aftercare
Contraception Options
IUDs
Your guide to IUDs
Mirena
Copper
The Pill
Your guide to the pill
Combined Pill
Mini Pill
Other contraception
The Jab
The Rod
Emergency Contraception
Learn more
Costs
Abortion Cost
Abortion cost overview
Funded
Private
Non-residents
Contraception Cost
Contraception cost overview
FAQ
Get in touch
Contact us
Our locations
Patient referral
Feedback and complaints
Request Appointment
