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Prevention – Rehabilitation – Performance
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Search:
Home
About us
Our Approach
Services
Injury Prevention
Rehabilitation
Performance
Complete Orthotic Solutions
Orthotic Assessment Clinic
3D Printed Insoles
Download Orthotics Catalogue
Referrals
Private Referrals
ACC Referrals
Public Health Funded Referrals
Referral Forms
Technology
Gait Track
FES Technology
Blog
Case Studies
Contact
FAQ
Give us your Feedback
Referral Forms
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Referral Forms
Please complete the form below to refer a patient.
Web Site
Service Location
*
Outpatient
Inpatient
Patient Details
*
First Name
Last Name
Date of Birth
Patient Gender
*
Male
Female
Other
Patient NHI
*
Citzenship
*
NZ Citizen
NZ Resident
Refrugee
Work Visa
Ethnicity
New Zealand European
Maori
Samoan
Cook Island Maori
Tongan
Niuean
Tokelauan
Fijian
Other Pacific People
Chinese
Indian
Other Asian
European
Other
Interpreter Required
Yes
No
Patient Contact Details
*
Town/City
Suburb
Postcode
Phone
Mobile
Email
Alternative Contact Details
Phone or Mobile
Referrer Details
*
Referrer Designation
Referrer Registration Number
Referrer Mobile Number
Referrer Phone Number
Referrer Email
Please Select Service
Please Select Service
General Practice
Allied Health - DHB
Allied Health - non-DHB
Dermatology
Diabetes
Dialysis
Emergency Department
General Medicine
General Surgery
Old Persons & Rehabilitation (Geriatrics)
Haematology
Neurology
Oncology
Orthopaedic
Orthotics
Paediatric
Pain Clinic
Physical Medicine Specialist
Plastic Surgery
Podiatry
Rheumatology
Vascular Surgery
Wound Care
Other
Consultant (DHB only)
Is the patient self referred?
*
Yes
No
Referred From
Ward
Clinic
Private Clinic
Medical Practice
Is this a result of an ACC covered injury?
*
Yes
No
ACC Claim No
*
ACC Date of Injury
*
Is this due to an ACC elected surgery?
*
Yes
No
Lead Provider
Is this patient new to the service?
*
Yes
No
Diagnosis
*
Treatment Goals
*
Is this referral for the review of current Orthotic, Insoles, Footwear or Splint?
*
Yes
No
What existing conditions does the patient have?
*
Diabetic
Active Ulcer
Open Wound
Wheelchair Bound
Visually Impaired
Hearing Impaired
Amputation
Other
Is this Patient a Fall Risk?
*
Yes
No
Patient Documents
Add Files
Upload any relevant patient documents
Further comments
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