Nurse talking to a person

Referral Form

If you have been diagnosed with Parkinson’s or Parkinsonism and you would like to hear from one of our Parkinson’s Educators please complete the referral form or call us on 0800 473 4636. We will then arrange for one of our Parkinson’s Educators to contact you.

Parkinson's Educator Service Referral Form

Complete the online form or download the pdf.

Client Details


Whānau/Next of kin
Referrer Detail

Does the patient agree to the referral?

Is the GP aware of the referral?

Medical History
Reasons for referral
Hazards (e.g. Dog on property, a smoker etc.)
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