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  QUICK REFERRAL

  Referral is easy. Please contact us using the form below. We will respond within 2 days setting out the options for referral, including whether the patient is eligible to be covered by any DHB funding, according to our contracts.

  Referrer:

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  Referrers Address:

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  Referrers Email:

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  Patient Name:

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  Patient NHI Number:

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  Patient DOB: Sex M/F: MF

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  Ethnicity:

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  Main Diagnosis:

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  Why the patient needs QE:

  Rheumatology Specialist
  Physiotherapy
  Occupational Therapy
  Orthotics
  Psych/Counselling
  Spa
  

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  Comorbilities, allergies:

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  Additional Info:

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