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Join Green Prescription

All you need to do is speak with your GP, or fill in the GRX Self-Referral Form.

Back to Green Prescription for Participants

GRX Self Referral Form

Green Prescription is a free programme for NZ residents, providing information, support and encouragement to help you into a routine with you physical activity and help you achieve you healthy lifestyle goals.

Personal Details

First Name

Surname

Gender

Date of Birth

Ethnicity

Other, please specify

Address

Contact Phone Number 1

Contact Phone Number 2

Name of GP

Name of Medical Practice

Health Details

Have you any injury, illness or pain that may be aggravated during exercise?

Have you, or have you had

High Blood Pressure
Arthritis
High Cholesterol
Type 2 Diabetes
Heart Problems (if so please specify in other medical conditions below)
Diabetes
Pre-Diabetes
Gestational Diabetes
Depression
Weight Issues

Other medical conditions

Are you a smoker?

What do you aim to achieve with your GRX?

What physical activity do you currently partake in?

What kind of exercise would you like to try while on GRX?

Preferred initial contact

Preferred time for contact

I consent for Sport Taranaki's Green Prescription team to obtain a referral from my medical practice in order to participate in the programme

Your form can only be submitted if all fields are filled in. An acknowledgement will be shown as soon as your form is successfully submitted.

Contact:

T: (06) 759 0930

F: (06) 759 1779

A: Maratahu St,
New Plymouth
New Zealand

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