Full Name (of person being referred) * Date of birth * Address * Phone number * Email address * If your med centres is NOT listed make direct contact to request a referral Reefton Medical Buller Medical Coast Medical Te Nikau Medical Coastal Health Ltd Westland Medical Centre You (Or the person being referred) must meet all the following criteria: * 18 years or older inactive (<2.5 hours physical activity per week) Want to increase physical activity motivated for change Green Prescription Plus Name ( if completing this referral for someone else) Profession Contact details * Consent to the West Coast Primary Health Organisation Green Prescription team contacting Medical Centre for further information I consent OR I have discussed this with the referee and they have provided consent