Orthotic House Referral Form

Waikato, Coromandel and King Country: Ph: 07 838 0606 – Email: info@orthotichouse.co.nz
Lakes District: Ph: 07 838 0606 – Email: info@orthotichouse.co.nz
Hawkes Bay: Ph: 06 870 3736 – Email: hastings@orthotichouse.co.nz

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Referral date *

Patient NHI *

Patient name

Patient title *

Patient first name *

Patient middle name

Patient Last name *

Patient gender *

Funding source *

ACC claim no. *

ACC date of injury *

Date of birth *

Ethnicity

Interpreter required *

Interpreter language *

Does the patient have an infectious disease?

Yes
No
Not known

Contact details *

Street address *

Town/city *

Post code

Phone *

Alternative contact details

Alternative contact name

Alternative contact phone

Service location *

Outpatient service location
Inpatient service location

Inpatient Service Location (Hamilton, Hastings and Rotorua) *

Hamilton
Hastings
Rotorua

Inpatient service location specify *

Outpatient service location *

Hamilton - Orthotic House, 60 Lake Road, Frankton, Hamilton
Matamata - Polhen Hospital outpatients, 56 Rawhiti Ave, Matamata
Te Kuiti - Te Kuiti hospital, 24 Ailsa Street, Te Kuiti
Thames - Thames Hospital Outpatients, 610 MacKay Street, Thames
Tokoroa - Tokoroa Hospital Outpatients, 75 Maraetai Road, Tokoroa
Rotorua - Rotorua Medical Group, 1181 Amohia Street, Rotorua
Taupō - Taupo Hospital Outpatients, 38 Kōtare Street, Hilltop, Taupō
Hastings - 1011-1013 Heretaunga Street West, Hastings
Waipukurau - Tuki Tuki Medical Centre, 1 Cook Street, Waipukurau

Diagnosis and treatment details

Details/notes

Attach files

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Referrer *

Referrer name *

Referrer designation *

Referrer registration no.

Service *

Other service *

Referrer phone *

Please send me an email confirmation with a copy of this form attached.

Please send me an email confirmation with a copy of this form attached.

Referrer email *