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Orthotic Service
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Referrals (orthotics)
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Referral to Hamilton Orthotic Service
Referral to Hamilton (Waikato) Orthotic Service
Date of Referral
(Required)
YYYY slash MM slash DD
Patient Name
(Required)
Title
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
First
Last
Patient NHI
(Required)
Ethnicity
(Required)
African
Asian
Chinese
Cook Islands Māori
European
Fijian
Indian
Latin American
Māori
Middle Eastern
Niuean
New Zealand European
Other European
Other Pacific Peoples
Samoan
South American
Tokelauan
Tongan
Unknown
Interpreter Required?
Yes
No
Interpreter Language
Dutch
Greek
Hungarian
Italian
Japanese
Korean
Pashto
Polish
Portuguese
Romanian
Russian
Thai
Turkish
Vietnamese
Other
Contact Details
Street Address
Town/City
Postcode
Mobile Phone
Patient Email Address
Alternative Contact Details
Name
Phone
Relationship to Patient
Service Location
Inpatient Service
Waikato Hospital
Outpatient Service
Waikato Orthotic Service (222 Pembroke Street, Hamilton)
Regional Clinic
Regional Clinic
Thames Clinic, 210 Richmond Street, Thames
Te Kūiti Hospital, 24 Ailsa Street, Te Kūiti
Tokoroa Clinic, Gate 1, Main Entrance, Maraetai Road, Tokoroa
ACC Referral
Is this an ACC Referral?
Yes
No
ACC Date of Injury (if applicable)
Day
Day
1
2
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4
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31
Month
Month
1
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Year
Year
2027
2026
2025
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2023
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1927
1926
1925
1924
1923
1922
1921
1920
ACC Claim No (if applicable)
Diagnosis and Treatment Required
Diagnosis and Treatment Details
(Required)
Would you like to add a file to this referral?
Max. file size: 4 GB.
Does the patient have an infectious disease?
Yes
No
Not known
Referrer Details
Referrer Name
(Required)
Referrer Email
(Required)
Referrer Designation
(Required)
Registration Number
Referrer Email
(Required)
Consultant (DHB Referrals Only)
Department
General Practise
Allied Health - DHB
Allied Health - Non DHB
Dermatology
Diabetes
Dialysis
Emergency Department
General Medicine
General Surgery
Old Persons & Rehabilitation (Geriatric)
Would you like an email confirmation with a copy of this form?
Yes
No
Email address to send copy of referral to
(Required)
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