Client referral 

You can refer a 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 private, unless covered by ACC. 

If you have any further queries please contact us.

  • Patient Information
  • Contact Details
  • Referrer details
  • ACC
  • Diagnosis / Others

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

Email

Name

Alternative Contact Details

Name

Email

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