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ReferTono Taurima
Contact Us

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ServicesNgā Ratonga
Getting HelpRapu Taituarā
About UsNgā Mātou
ReferTono Taurima
Contact Us

ReferGrant Difford2025-11-21T12:27:54+13:00

Refer to Access and Total Care Health

Use the Referral form below to refer yourself, or someone else for home support and/or nursing services, including ACC-funded wound care. This form is for Access and Total Care Health referrals.

ACC self-referral If you had an accident and need ACC-funded wound care e.g. skin tear, you can refer yourself directly to us without visiting your GP. This applies if you cannot get a timely GP appointment and/or it is physically challenging for you to get to the clinic.

Health professionals please use the Referral form or refer via SR from your PMS.

START REFERRAL

Referral form

Referral Form Website Parent

I am referring

Myself

Someone else (e.g. patient, client, family member)

Name *

First

Last *

Last

Email *

Phone

Home address *

Location *

Date of Birth

Gender

Ethnicity (select all that apply)

African

Asian

Chinese

Cook Island Māori

European

Fijian

Indian

Latin American or Hispanic

NZ European or Pakeha

NZ Māori

Samoan

South East Asian

Tokelauan

Tongan

Other Pacific

Other Ethnicity

Prefer not to answer

NHI number (if known)

Is the reason for your referral the result of an accident? *

Reason for referral *

Please provide details if you have selected 'Other'

Have you had a Needs Assessment (NASC)? *

Yes

I don't know

Do you have an ACC claim number *

What is your ACC claim number? *

Please complete the following information:

Occupation *

Employer *

Date/time of injury *

Where did the injury take place? (e.g. home/workplace/sports field etc.) *

Nature of injury (e.g. laceration right lower leg) *

Description of incident (e.g. fell and landed on chair) *

Please provide any other information which may be useful to us

Referrer Details *

Referrer First Name

Referrer Last Name *

Referrer Last Name

Referrer Organisation (if you have one)

Preferred first visit date (if clinically required)

Referrer Phone *

Referrer Email *

Relationship to person being referred *

Please provide relationship details if you have selected 'Other'

Please provide details of person being referred

Name *

First

Last *

Last

Email *

Phone *

Home address *

Location *

Date of Birth

Gender

Ethnicity (select all that apply)

African

Asian

Chinese

Cook Island Māori

European

Fijian

Indian

Latin American or Hispanic

Middle Eastern

Niuean

NZ European or Pakeha

NZ Māori

Samoan

South East Asian

Tokelauan

Tongan

Other Pacific

Other Ethnicity

Prefer not to answer

NHI number of person referring (if known)

Is the reason for referral the result of an accident? *

Reason for referral *

Please provide details if you have selected 'Other'

Has the person you are referring had a Needs Assessment (NASC)? *

Yes

I don't know

Does the person you are referring have an ACC claim number *

What is their ACC claim number? *

Please complete the following information on behalf of the person being referred

Occupation *

Employer *

Date/time of injury *

Where did the injury take place? (e.g. home/workplace/sports field etc.) *

Nature of injury (e.g. laceration right lower leg) *

Description of incident (e.g. fell and landed on chair) *

Please provide any other information which may be useful to us (If you are a health professional, please include as much clinical information as possible.)

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