AH Prescreening Form (Non-registered)

After-Hours Subsidy Request - NON-REGISTERED Patients

PLEASE NOTE: This subsidy is only available to patients who are NOT registered with any medical provider are resides within the Te Puke district and surrounds
Full Name*

First NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Contact Number*

Prefix (027, 021, 022)Number
Email*
example@example.com
NHI (if known)
Thank you for your request to access a subsidized After Hours appointment.

Our system will review your details and once eligibility is confirmed, you will receive an email with your unique discount code and instructions to book your appointment via Practice Plus.

Ngā mihi
Tēna koe,

You have reached us outside of operating hours.

PLEASE NOTE: If you are experiencing a medical emergency, please call 111 immediately

After-Hours operating hours are:

Monday – Friday: 5.00pm to 10.00pm

Saturday & Sunday: 8.00am to 8.00pm

If you are trying to contact us during normal business hours (Monday-Friday: 9.00am – 5.00pm), please call 07 5730660 and one of our staff will be happy to assist you.

Ngā mihi,

After-Hours Team
Time

:HourMinutes
DateTime
Should be Empty:

After-Hours Subsidy Request - NON-REGISTERED Patients