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- Naturopathy
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Referral Form

Please fill out the following form if you are a healthcare provider / practitioner or therapist referring a patient.

Practitioner First name*

Practitioner Last name*

Practitioner Email*

Practitioner contact phone

Which clinic or practice do you work at?

Patients Full Name*

Patients Date of birth*

Day

Month

Year

Patients Email*

Patients phone number*

Patients ACC number (if applicable)

Date of injury (if applicable)

Does this patient require treatment:

less than 1 week (acute)

2-3 weeks (sub-acute-chronic)

Please briefly describe the reason for referring and the patients condition.*

Which therapy are you wanting to refer for:*

Osteopathy

Acupuncture

Pain Specialist

Baby Sleep Consultant

Massage Therapy

Clinical Lymphatic Drainage

Other comments:

Phone:

Hours:

Queenstown:

Mon - Fri: 8am - 7pm

Sat: By appointment only

Sun: By appointment only

Wanaka:

Mon - Fri: 8am - 7pm

Queenstown Location:

18 McBride Street, Frankton 9300

Wanaka Location:

33 Reece Crescent

Wanaka 9305

Metamed and Peak Potential are now part of Laryn Allied Health.

Contact Us:

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