Casual Register Form Caring Clinic Doctors v1.3e

Caring Clinic Doctors Casual Form

Level 8, 175 Queen Street, Auckland 1010 Ph09 2222577 Fax09 2222575 EDI:caring8q GP2GP: Dr R Sim MCNZ38537
Fill this form only if you have never been to our clinic or if you are requested to update some of your details. Thanks.

If you believe you are eligible for NZ healthcare enrolment, please click here instead for enrolment form with Caring Clinic Doctors.
Name ：*

Title First Name Last Name
DOB ：*

DayMonthYear
Date
Mobile ：*
phone number
Gender ：*

MaleFemaleOther
Ethnicity Details*

New Zealand EuropeanChineseMaoriSamoanCook Island MaoriTonganNiueanIndianOther
Address :

street address

Street Address Line 2

City State / Province

Postal / Zip CodeCountry
Email：*
example@example.com
NHI number (if known)：
NHI =national health index number
Emergency Contact's Name：*
Name of next of kin/ emergency contact
Contact- Phone number：*
ideally phone number, otherwise email/ others
Contact- Relationship：*
Family/friend/etc
Please upload a copy of your photo ID (i.e. Passport/ Driver license)- suggestion: scan and add, or take a photo and attach.

Browse Files
can upload more than one files (including jpeg/ pdf etc) Cancelof
Signature ：

Clear
sign above the line
If signed by AUTHORITY ：

Caring Clinic Doctors Casual Form