Auckland Gynaecology Group | Contact Us | Patient Registration Form

Patient Registration Form

To speed up the process please fill this form prior to your arrival.

Patient's Full Name (This must be your legal name as on your birth certificate or passport)*

Known As

Address*

DOB

Sex

NHI Number

Phone Number

Work Number

Mobile

I CONSENT FOR MY MEDICAL INFORMATION TO BE SENT/RECEIVED ELECTRONICALLY/EMAIL.*

Yes No

Email Address*

CURRENT GP:*

Referring Doctor if different from above:

ALLERGIES

Medical Insurance Company:

Ethnic Group

Occupation

NZ Citizen/Resident*

Yes No

NZ 2 Year Work Permit*

Yes No

I agree to accept charges on overdue accounts, and to accept charges for all reasonable costs incurred in recovering outstanding amounts, including debt collection and legal fees, should this be applicable.*

Yes No

* Required.

Patient Registration Form

To speed up the process please fill this form prior to your arrival.

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