You can refer a private or ACC client to Orthopro by using the form below or emailing your prescription to firstname.lastname@example.org
If a client is eligible for funding by their local District Health Board (DHB) or Ministry of Health (MOH) the referral must be sent to the relevant DHB directly in order to be considered for funding. Any referrals received by Orthopro directly will be treated as a private referral, unless covered by ACC.
If you have any further queries please contact us.
- Patient Information
- Contact Details
- Referrer details
- Diagnosis / Others
Date of Birth
Alternative Contact Details
Is this a result of an ACC covered injury
ACC Claim Number
Please provide details of client diagnosis
Orthotic/Prosthetic Treatment Objectives
Further Comments (Please provide any further comments that may aid in the treatment of our client, such as level of urgency, preferred appointment days or times, special needs etc.)
Client Documents (Upload any client documents)
Max. size: 128.0 MB