The Airport Doctor Enrolment Form

The Airport doctors Enrolment Form

3/400 George Bolt Memorial drive, Auckland Airport Auckland, Phone: 09 2568655 Fax: 092568460, Email: reception@airportmedics.co.nz EDI: airoaks

Personal Details
Name*

First NameLast Name
Title
Gender*
Gender diverse, please state if applicable
Other names and preferred name

Other names known by (eg. maiden name, etc) Preferred name
NHI if known
Date of birth*

DayMonthYear
Date
Place and Country of Birth

Contact Detail
Address*

Street Address

Subur

CityRegion

Post CodeCountry
Postal Address

Same as above Different from above
Postal Address
Day Phone

Area CodePhone Number
Night Phone

Area CodePhone Number
Mobile number*

Area CodePhone Number
Accepting Text to Your Mobile

YesNo
Email*
example@example.com
Occupation
Emergency Contact

First Name   Last Name   Relationship

Area Code   Phone Number

Email

Subsidy cards
High User Health Card Holder

YesNot
High User Health Card Number
High User Health Card Expiry Date

DayMonthYear
Date
Community Services Card Holder

YesNo
Community Services Card Holder Number
Community Services Card Holder Number Expiry Date

DayMonthYear
Date

Transfer of Records
Transfer of Records

YesNoNot Applicable
In order to get the best care possible. I agree to the transfer of my records from my previous doctor. I understand I will be removed from their practice register.

Doctor's Name   First Name   Last Name

Clinic name:Clinic Name

Address: Street Address   Suburb   City      Post Code


Phone: Area Code   Phone Number