Health Equip Order Form

HEALTHCARE EQUIPMENT HIRE – ORDER FORM

This order will be submitted to Health Equip immediately and a copy will be sent to you as confirmation
Patient Information
Name*

First NameLast Name
Date Of Birth:*

DayMonthYear
Mobile Number:*
Patient Residential Address*
Address*

Street Address

Street Address Line 2

CityState / Province

Post Code
Email*
example@example.com
NHI:*
Alternative Contact Information

(Family/friend etc)
Referred By:

Physio/Surgeon etc
Referrers Email - for copy of completed form*
example@example.com
Referred by:*

HospitalAllied ProviderOther
Name of Hospital:
Equipment Hire Information
Discharge Date*
Estimated length of hire*
Is Delivery required?*

YesNo
Any delivery instructions?
Delivery address - if different from residential address:
Funder (Please Tick)*

Private PayingFunded by an organisationOther
Type of Organisation:
ACC Number:*
Insurance Provider:
Required Equipment
** Please click Save after each new item ***
Additional Comments:
Health Equip shall contact the hirer within 24-48 hours of receiving the equipment order form to arrange item delivery or collection from its office. We send out documentation electronically for client’s ease. For any questions, please do not hesitate to contact our team.
Healthcare Provider Authorisation
I, Name, hereby authorise the referral of the above-named patient to Health Equip for the provision of mobility equipment. I confirm that the information provided in this referral form is accurate to the best of my knowledge.
Signatory Details
Name (Provider Representative):*
Signature*

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Date Signed*
For any enquiries or assistance, please call 09-869 6190 or email admin@healthequip.co.nz

Thank you for your referral. We look forward to providing excellent service to your patient.
Should be Empty:

Patient Information

Alternative Contact Information

Referred By:

Equipment Hire Information

Required Equipment

Healthcare Provider Authorisation

Signatory Details