Patient name

Date of birth

Email

Home phone

Mobile phone

Address

Referrer name

Patient Details

ACC45 Claim Number

Date of Injury

Patients preferred participating physio clinic for referral:

Treatment Referral

Knee

Ligament Rupture

ACL PCL MCL LCL Multi-Ligament Rupture

Tendon Rupture

Patellar Tendon Rupture

Meniscal

Medial and/or Lateral Meniscal tear or other internal derangement

Instability

Traumatic Patellar Dislocation

Fracture

Fracture involving the tibial condyle Fracture involving the femoral condyle Fracture of the patella Osteochondral fracture

PTOA

Post-Traumatic Osteoarthritis

Shoulder

Tendon Rupture

Rotator cuff full thickness tear (rupture) +/- Biceps tendon high grade tear

Instability

Glenohumeral joint dislocation +/- Traumatic Labral tear AC Joint dislocation

Fracture

Fracture glenoid (or scapular end of shoulder) Fracture of humerus (or humeral end of shoulder) Fracture clavicle

PTOA

Post-Traumatic Osteoarthritis

Lumbar Spine

Disc

Lumbar disc prolapse, or extrusion, with radiculopathy

Fracture

Lumbar fracture

Other - Metalware Removal

Previous fracture mentioned above managed with ACC funded surgery, now requires metalware removal

Treatment Plan

Plan

Surgical Non-Surgical

Proposed Date for Surgery (if applicable)

Additional Patient Information

Is this injury the only current injury?

Yes No

If no to the above please describe below

Does this patient have medical comorbidities that could affect their rehab?

Yes No

If yes to the above please describe below

Imaging

Attached to Referral

XR USS MRI CT

Referral Made

XR USS MRI CT

Vocational Assessment

Employment type

Paid employment in New Zealand Self-employed in New Zealand Not in paid employment

Patient currently off work

Yes No Fit For Some Work

Medical certificate (ACC18) completed

Yes No

Administration:

The following has been attached to this referral:

Clinical History Consultation Notes Imaging ARTP (if appropriate) BAU Surgery Approval (if appropriate) Medical Certificate (if appropriate)

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