Immigration Medical Register Form Caring Clinic Doctors v1.3e

To register for a NZ immigration medical please fill out the form below.
Name (as it appears on your passport) ：*

Title First Name Last Name
DOB ：*

DayMonthYear
Date
Mobile ：*
phone number
Email：*
example@example.com
Gender ：*

MaleFemaleOther
Are you pregnant?

YesNoUnsure
Ethnicity Details

New Zealand EuropeanChineseMaoriSamoanCook Island MaoriTonganNiueanIndianOther
Country of birth:
Address (NZ residential Address) :*

street address

Street Address Line 2

City State / Province

Postal / Zip CodeCountry
Current Visa Status:*

Visitor's VisaStudy VisaWork VisaResidence VisaOther
Current Visa Status:*

Visitor's vVisaStudy VisaWork VisaResidence VisaOther
What Visa are you applying for (proposed visa application type):

Visitor's visaStudy VisaWork VisaResidence VisaOther
What Visa are you applying for (proposed visa application type):*

Visitor's VisaStudy VisaWork VisaResidence VisaOther
How long are you intending to stay in New Zealand for this time?*

under 6 months6-12 months12- 24 monthsmore than 24 monthsOther
How long are you intending to stay in New Zealand for this time?*

under 6 months6-12 months12-24 monthsmore than 24 monthsOther
Please upload a copy of your Passport here:

Browse Files
can upload more than one files (including jpeg/ pdf etc) Cancelof
Please upload a copy of immigration requirement Letter/ Email screenshot here:

Browse Files
can upload more than one files (including jpeg/ pdf etc) Cancelof
Do you have any medical conditions/ previous medical issues ? (can briefly enter here eg hypertension, diabetes, depression)
This just help us prepare certain extra check up if need be for you,
Have you read the eMedical Client Declaration ?*

Yes, I have readNo, I haven't readUnsure, I will find out later (staff will give you a copy onsite)
Yes , I have readNo, I haven't readUnsure I will find out later
Signature ：*

Clear
sign above the line
If signed by AUTHORITY ：

open up if clicked not self signed
Name of authority：

Title First Name Last Name
Relationship to patient：
eg. parents/ wife/ husband/ guardian etc
Phone Number:

Area CodePhone Number

end of authority info
Should be Empty: