Hauora Form

This form is for new clients to fill out before their session.

First Name

Date of Birth

Hapū (If applicable)

Last Name

Phone

Address

Iwi (If applicable)

Have you been hospitalized in the last 12 months?

Yes

Are you suffering from a medical condition, illness, or injury?

Yes

If you answered yes to any question, please elaborate here as well as any medication you are on.

Are you a Private Client or ACC?

If this is under an ACC claim, please check the box if it is an Injury or Sensitive Claim.

Sensitive

Injury

Not sure

Have you had Mirimiri or Rongoā before?

Were you referred to us, if so, who referred you?

Next of Kin

Next of Kin Phone Number

What are your health goals? Be specific

How did you hear about us?

Initials

I declare that the info I’ve provided is accurate & complete

I accept terms & conditions

Nga mihi. Thanks for submitting

RONGOĀ, MAURI + RECIPES WORKSHOPS, WĀNANGA + RETREATS