Green Prescription Referral Form for Health Professionals

Section 1 - Patient Details

Section 2 - Medical Conditions

Patient Medical Conditions
Respiratory conditionsDepression/AnxietyCVDHigh CholesterolHeart ConditionsStrokeStressHigh Blood PressureLow Blood PressureWeight Loss SupportArthritisInjuryMental Health ConditionsEpilepsyJoint replacementOsteoporosis


Pre-diabetic (HbA1c 41-49mmol)Gestational DiabetesType 2Type 1

Current Physical Activity

What level of intensity is their activity?(choose one)LowMediumHigh

Stanmore BayAlbanyGlenfieldWestWave, HendersonWestCity Mall, HendersonThe Fono, HendersonYMCA, Massey

Section 3 - Referral Information

By ticking this, I confirm that I have explained the GRx process and that the patient has consented for their details to be forwarded to Harbour Sport Grx, who will provide them with support and advise.

Share This