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Health Professional Referral for CCIS Support
This referral form is for Health Professionals to refer their clients to Complex Chronic Illness Support. This referral will be assessed and a qualified Field Officer will contact your client directly with the contact details given within 2 weeks.
Health Professional referring
*
Health Professional Email Address
*
Health Professional Contact details
*
email, phone, practice
Clients name
*
First name
Last name
Persons address
*
Address line 1
Address line 2
Address line 3
Address line 4
Town/Suburb
City
Postcode/Zip
Email address
Cell phone
Home phone
*
Preferred contact method
Email
Text
Letter
Phone
Facebook
Slack
Cell
Medical Condition
*
(CFS / ME) Chronic Fatigue Syndrome
(FM) Fibromyalgia
(OI) Orthostatic Intolerance
(POTS) Postural Orthostatic Tachycardia Syndrome
(PVS) Post Viral Syndrome
Long-COVID
Not yet Diagnosed
Further Information:
Did you know?
CCI Support has a Health Professional pack available online or sent out. More information can be found on our website or request more brochures etc below.
Website
CCI Support Website
How did you hear about CCI Support?
Would you like:
No extra information required thanks
A Health Professional Information Pack sent out please
Client Brochures sent out please
43 Welcome Bay Rd, Welcome Bay, Tauranga 3112
P: 022 658 0251 or 0800 224 7871
E: info@ccisupport.org.nz
W: www.ccisupport.org.nz
Please check the highlighted fields
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