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