Refer a patient to Green Prescription

GRX Self Referral Form

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

Referrer Details

Name

Contact Phone Number

Referrer Profession

Other, please specify

Organisation

Department (if applicable)

Would you like to receive an email update when your patient has been discharged?

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

Initial Contact Preferences

Preferred initial contact

Preferred time for contact

I have obtained consent from my patient to receive Green Prescription support. My patient also consents for Sport Taranaki's Green Prescription team to obtain a referral from their 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.

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Refer a patient to Green Prescription