Client Referral Referral type - please choose one * Self-referral Referred by health professional CONTACT DETAILS OF REFERRER Name of referrer * First Last Agency name (if relevant) Phone * Email Address CLIENT DETAILS Client name * First Last Address Address Line 1 * Address Line 2 City * Phone Email Address Date of Birth NHI number (if known) Is the person being referred one of the following? A person with MS A person with a related condition Whānau Carer Other Reason for referral * By submitting this form I, the referrer, have obtained verbal permission from the client named above, or if self referred, give permission to be contacted by MS Otago. I authorise MS Otago to store my information * I agree