Client referral
You can refer a private or ACC client to Orthopro by using the form below or emailing your prescription to book@orthopro.co.nz
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.
Personal Information
First Name
Surname
Date of Birth
NHI Number
Gender
Contact Details
Street Address
Suburb
Town/City
Postcode
Phone 1
Phone 2
Phone 3
Name
Alternative Contact Details
Name
Referrer details
Referrer Name
Referrer Designation
ACC
Is this a result of an ACC covered injury
ACC Claim Number
Diagnosis
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