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Get in touch:

Phone: 0800 687 748

Fax: 07 838 0152

Email: info@otrs.co.nz

Address:

Hamilton Wellington

Suite 3, Level 1 65 Waterloo Road

169 London Street, Hutt Central

Hamilton Central, 3204 Lower Hutt, 5010

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Patient Name

Street Address

Town or City

Phone Number

Additional Contact Details: (Mobile Numbers and Email Address)

Date of Birth

Diagnosis

Reason for referral (please include MOCA or MINI ACE score and current medications list) GP please email these to info@otrs.co.nz or fax any other relevant information to 07 838 0152

Additional Comments or Concerns

GP or Specialist Name and Designation

Clinic or Practice Name

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GP or Specialist Contact Number

Please tick if receipt of referral or a copy of the referral is required

Address

Thank you, your referral has been sent successfully and the OTRS Team will be in touch to arrange your assessment. A report will be sent once the assessment has been completed.

Please click the download to view the Medical Fitness to Drive Consent Form

Get in touch:

For clinicians only:

Make a referral:

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