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Orthotic Service Referral Form

Referral details

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Location(Required)

Referral date(Required)

Orthotic Service(Required)

Inpatient referral

Outpatient referral

Peke Waihanga community clinic

Outpatient

If inpatient, please select location

If other - please specify

Specify ward/department

Side(Required)

Left

Right

Bilateral

Primary diagnosis (note any amputations/active wounds)(Required)

Bracing objective(Required)

Date of amputation (if applicable)

ACC Information (if applicable)

Date of injury

Claim number

Patient details

Patient NHI(Required)

Date of Birth(Required)

Patient title

First name(Required)

Last name(Required)

Ethnicity(Required)

Patient gender

Other gender (specified)

Contact phone number (mobile preferred)(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

General practice name

GP name

Alternative contact details

Alternative contact person - first name

Alternative contact person - last name

Relationship to patient

Relationship - other

Contact mobile number

Health considerations

Relevant medical history (tick all that apply)

Untitled

Interpreter required

Interpreter language

Does the patient have a current infectious disease?(Required)

Yes (please specify)

Unknown

Please specify

Are there any safety considerations or support needs we should be aware of for this patient?(Required)

Select any that apply and make a note in the comment box

Support with communication and understanding is needed

There are factors that may cause distress or discomfort (e.g. environment, procedures, or interactions)

There are considerations that may impact safe care delivery (e.g. history of escalating behaviour, requires a support person, close monitoring)

There are specific approaches or strategies that work well (e.g. best approaches, things to avoid, successful de-escalation techniques)

N/A

Comment

Does this patient have a history of falls or present with mobility or balance issues?

Mobility aids (please specify):

Referrer Details

Name(Required)

Role

Phone(Required)

Email(Required)

Referring hospital department & ward

Same as inpatient ward/department

Please specify

Hospital/Ward/Department

Please send me an email confirmation of this referral

Yes