Casual Patient Register Form 非居民注册表
655 Dominion Road, Mt Eden, Auckland, 1041
Name
*
First Name 名
Middle Name
Last Name 姓
Gender 性别
*
Please Select
Male
Female
N/A
Date of Birth 出生日期
*
-
Day
-
Month
Year
Date
Address 住址
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail 电子邮箱
*
example@example.com
Mobile Number 手机号码
*
-
Area Code
Phone Number
Visa
Please Select
NZ Citizen
NZ PR
NZ Resident
Work Visa
Student Visa
Visitor Visa
Please upload copies of your passport, VISA or birth certificate 请上传您的护照、签证或出生证明的复印件
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