Join GRx | Sport Manawatu

Joining Green Prescription is easy. Follow these 2 simple steps.

Step 1:

Speak with your General Practitioner, Practice nurse or fill in the GRx Self-Referral Form

Step 2:

Read through the GRx Consent Form

GRx Self-Referral Form

If you are a human and are seeing this field, please leave it blank.

Your Name *

Surname *

Gender *

Male
Female

Date of Birth *

Other, please specify

Please tell us of any cultural requirements you have

Address *

Email *

Home Phone

Work Phone

Mobile Phone *

How do you prefer to be contacted *

Phone
Email

Emergency contact name *

Emergency phone number *

Your GP *

Your GP Practice: *

Other, please specify

Health Details

Have you any injury, illness or pain that may be aggravated during exercise? *

If yes to any of the above, is there any information that may affect your ability to enjoy physical activity?

Are you a smoker or have you given up in the last year?

Have any of your immediate relatives had

Heart problems before the age of 60
Diabetes
Gout

Please list any medications you are now taking *

Your current exercise

What kind of exercise are you doing at present?

How many times each week?

Do you belong to any sports club or activity group at present? If so please list

Is there an event that you would like to aim at, and when is it?

Other, Please specify

Consent

Click here for the consent form

Click here to consent *

Katrina Gemmell
Green Prescription Advisor

I run weekly educational and activity classes. Contact me if you would like information on physical activity or exercises that might be right for you.

Phone: 06 357 5349 ext 748
Email: katrinag@sportmanawatu.org.nz