Southern Cross Health Society Affiliated Provider
info@agg.co.nz
09 524 1222
09 524 1221
Home
About us
Our Team
Gynaecology Services Auckland
Contact Us
Satellite Clinics
Useful Links
Patient Registration Form
Menu
Home
About us
Our Team
Gynaecology Services Auckland
Contact Us
Satellite Clinics
Useful Links
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
Submit
* Required.
