Internal/Health Partner Referral
Integrated Care Pathway
Client details
Client’s full name:
*
First Name
Last Name
Claim number:
*
Date of injury
*
-
Day
-
Month
Year
Date
Date of birth
*
-
Day
-
Month
Year
Date
NHI number:
Email
example@example.com
Phone number
-
Area Code
Phone Number
Mobile number
-
Area Code
Phone Number
Patient residential address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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General entry criteria
Is there a valid ACC claim with a date of injury within the past 12 months?
*
Yes
No
Please put in the ACC45 or Claim number
Current working/Suspected diagnosis
Use dropdown to select the diagnosis (one body part/selection only)
Area of injury
*
Please Select
Knee
Shoulder
Back
Other
Current diagnosis
*
Please Select
Medial and/or Lateral Meniscal tear or other internal derangement
Fracture of the patella
Osteochondral fracture
Anterior Cruciate Ligament Rupture with/ without meniscal tear
Medial and/or Lateral Ligament Rupture
Traumatic Patellar dislocation
Posterior Cruciate Ligament Rupture
Post-Traumatic Osteoarthritis
Patellar Tendon rupture
Fracture involving the tibial condyle
Fracture involving the femoral condyle
Current diagnosis
*
Please Select
Fracture humerus (or humeral end of shoulder)
Rotator cuff full-thickness tear (rupture)
Fracture clavicle
AC Joint dislocation
Fracture glenoid (or scapular end of shoulder)
Glenohumeral joint dislocation
Post-Traumatic Osteoarthritis
Current diagnosis
*
Please Select
Lumbar disc prolapse, or extrusion, with radiculopathy
Lumbar fracture
Other
*
Please Select
Previous fracture (ACC-funded surgery) removal of metalware
Supporting information
Investigations Undertaken: Please attach relevant reports to referral
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Mechanism of injury
Was it caused by an accident?
*
Yes
No
What happened? (brief description of the accident)
*
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Referrers Signature
Full name
*
First Name
Last Name
Organisation/Clinic:
*
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Electronic signature
*
Date
*
-
Month
-
Day
Year
Send
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