Cromwell Family Practice Immigration Booking Form

Immigration Booking

Please fill out for all new e-medical cases, our staff will call you with a time that suits for your exam. Wait time is usually 1-2 weeks . You must see a Panel Clinic before having Xrays. Please email, not phone, with inquiries.
Cromwell Family Practice - Panel Physician Clinic

2 McNulty Road Cromwell

txt 021 2680422 email immigrations@cromwellfamilypractice.co.nz
Name*

PrefixFirst NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Gender*

MaleFemaleOther
Home Address (NZ)*

Street Address

Suburb

City

Post Code
Mobile Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Email*
If sharing, be aware your results and details will be sent here
Occupation*
Country of Birth*
Passport Number*
Passport Country*
Issue Date Passport*

DayMonthYear
Date
Expiry Date Passport*

DayMonthYear
Date
Proposed length of stay in NZ*
Exam Required*
Visa Type*
NZER or NZHR case number

Interpreter required?

Yes
Completed by*

PatientAuthorised Person (Parent or Caregiver to sign if under 16 years)Other
Name of authorised Person filling in on behalf

First NameLast Name
Relationship if filling on behalf
Signature (do your best!)

Clear

Deposit payment

Deposit to confirm booking$50.00NZD

Full medical $443 Child $150, Xray only $50, and Limited 2021 Visa $220, less the $50 deposit paid

Total $0.00NZD

Immigration Booking