For security reasons please enter your email(Required) Section BreakWho is this referral for?(Required) Someone else at my work Multiple employees/OtherDoes the team member have an ACC injury claim AND requires assistance to return to work (including a medical certificate)?(Required) Yes NoPlease complete this form instead ACC Vocational RehabilitationMultiple employees/OtherDo you require:(Required) Preventative Workstations Audits (for individuals experiencing pain or discomfort, pleases complete a separate referral form for each person) Group or one-on-one education Analysis of the physical demands of one or more job roles Other / UnsurePlease select region(Required)select regionNorthlandAucklandWaikatoBay of PlentyGisborneHawkes BayTaranakiManawatu/WhanganuiWairarapaWellingtonMarlboroughTasmanCanterburyWest CoastOtagoSouthlandAddress for the services to be delivered(Required)Please complete the details for each individual requiring a workstation audit Row ID Name EmailActions EditDelete There are no Participants. Add Participant Maximum number of participants reached. Please provide more details about the service you require and a member of our team will be in touch to discuss.Contact Details for Person Receiving the ServiceName(Required) First Last Date of Birth Phone(Required)Email(Required) Please select region(Required)select regionNorthlandAucklandWaikatoBay of PlentyGisborneHawkes BayTaranakiManawatu/WhanganuiWairarapaWellingtonMarlboroughTasmanCanterburyWest CoastOtagoSouthlandPreferred location of service delivery(Required) In-Clinic appointment Telehealth (Clinic in the Cloud)If an urgent appointment is required, please select “Virtually/Clinic in the Cloud – Telehealth Service” and state “Urgent referral” in the Additional Information field below.Is this referral urgent? i.e. Appointment must be within 2 business days Yes NoIf this referral is urgent and in-person appointments are unavailable, Telehealth may be offered to enable earlier assessment. Is this acceptable? Yes NoAre there any days or times during the week when the client is NOT be available for their initial appointment?(Required) Yes NoPlease specify when the client is NOT available (e.g. Monday mornings)Note that restrictions may result in delays in scheduling the assessment.Clinic assessmentDoes the person have:(Required) An injury Pain or discomfort Health condition No symptoms Unsure – please contact me to discuss appropriate servicePlease provide more details about the service you require and a member of our team will be in touch to discuss.Body Site of Symptoms(Required) Neck Back Shoulder Elbow Hand/Wrist Hip Knee Foot/Ankle Other (Please specify)Please specify site.Has the injury been lodged with ACC?(Required) Yes No UnsureWould you like our physiotherapist to lodge an ACC claim if appropriate?(Required) No – assess under Early InterventionADMIN NOTEIf ACC claim appropriate, please contact employer before lodging claimDo you have the ACC claim number?(Required) Yes NoACC Claim Number(Required)Is this a work injury?(Required) Yes NoSurcharge to be paid by:(Required) Our business (3 sessions)Surcharge to be paid by:(Required) ClientInvoice to be sent to:charlotte.derosa@meridianenergy.co.nzPurchase Order Number:(Required)Workplace AssessmentWhat is the address for the services to be delivered?(Required)Are there any health and safety risks the provider should be aware of when they visit the worksite?(Required) Yes NoPlease state health & safety risks.Is there any specific protective equipment or clothing the provider will need to bring to the visit?(Required) Yes NoPlease list protective equipment or clothing the provider will need.WDoes the person have:(Required) An injury Pain or discomfort Health condition No symptoms Unsure / Not ApplicableWHCUDo you require:(Required) Workstation/site assessment Return to work support (non-injury) Something else/unsure. Please provide more details about the service you require and a member of our team will be in touch to discussWNSDo you require:(Required) A Prevention Workstation Audit Something else/unsure. Please provide more details about the service you require and a member of our team will be in touch to discussBody Site of Symptoms(Required) Neck Back Shoulder Elbow Hand/Wrist Hip Knee Foot/Ankle Other (Please specify)Please specify site.Has had the injury been lodged with ACC?(Required) Yes No UnsureDo you have the ACC claim number?(Required) Yes NoACC Claim Number(Required)WIs this a work injury?(Required) Yes NoDoes the worker require assistance to return to work?(Required) Yes NoWDo you require:(Required) A workstation/worksite assessment Something else/unsure. Please provide more details about the service you require and a member of our team will be in touch to discussPlease complete this form instead ACC Vocational RehabilitationPlease provide more details about the service you require and a member of our team will be in touch to discussVirtually/Clinic in the Cloud-Telehealth AssessmentDoes the person have:(Required) An injury Pain or discomfort Health condition No symptoms Unsure / Not ApplicableDo you require:(Required) Virtual workstation/site assessment Return to work support (non-injury) Something else/unsure. Please provide more details about the service you require and a member of our team will be in touch to discussDo you require:(Required) A Prevention Workstation Audit Something else/unsure. Please provide more details about the service you require and a member of our team will be in touch to discussBody Site of Symptoms(Required) Neck Back Shoulder Elbow Hand/Wrist Hip Knee Foot/Ankle Other (Please specify)Has the injury been lodged with ACC?(Required) Yes No UnsureWould you like our physiotherapist to lodge an ACC claim if appropriate?(Required) No – assess under Early InterventionADMIN NOTEIf ACC claim appropriate, please contact employer before lodging claimDo you require:(Required) A Virtual workstation assessment A virtual physiotherapy assessment Something else/unsure. Please provide more details about the service you require and a member of our team will be in touch to discussPlease provide more details about the service you require and a member of our team will be in touch to discussDo you have the ACC claim number?(Required) Yes NoACC Claim Number(Required)Is this a work injury?(Required) Yes NoSurcharge to be paid by:(Required) Our business (3 sessions)Surcharge to be paid by:(Required) ClientInvoice to be sent to:charlotte.derosa@meridianenergy.co.nzPurchase Order Number:(Required)Contact Details for the Referrer & ManagerReferrer Organisation / Business NameMeridian EnergyManager's Name(Required) First Last Manager's Phone(Required)Manager's Email(Required) Is the Manager the Referrer?(Required) Yes NoReferrer's Name(Required) First Last Referrer's Phone(Required)Referrer's Email(Required) Business detailsBusiness Department(Required)Please ChooseCorporateWindHydroSolarCorporate Business Sites (Branch)(Required)Please chooseAucklandMastertonWellingtonChristchurchTwizelWind Business Sites (Branch)(Required)Please chooseTe UkuHarapakiTe ApitiMill CreekWest WindWhite HillHydro Business Sites (Branch)(Required)Please chooseWaitaki Scheme (Twizel)ManapouriSolar Business Sites (Branch)(Required)Please chooseRuakakaIs an assessment report required?(Required) YesWho should the report be sent to?health&safetyteam@meridianenergy.co.nzInvoice to be sent to:charlotte.derosa@meridianenergy.co.nzPurchase Order Number:(Required)Admin NotesADMIN NOTESet up as a ContractADMIN NOTESet up as a ConditionPlease select closest clinicPlease select your region(Required)Choose your regionNorthlandAucklandWaikatoBay of PlentyGisborneHawkes BayTaranakiManawatu/WhanganuiWairarapaWellingtonMarlboroughTasmanCanterburyWest CoastOtagoSouthlandNorthland Clinic Northland ClinicsActions EditDelete There are no Entries. 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