Health and Happiness
Immigration Medical Booking Form
How did you hear about us?
*
Family / Friend
Website
Google Ad
Neighbourly
Advertisement Sign/Flyer
Via another Medical Practice (i.e. Papatoetoe Family Doctors)
Name
*
Mr
Mrs
Miss
Dr
Prefix
First Name
Middle Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Is this patient under the age of 11?
Yes
No
Gender
*
Male
Female
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Phone
*
Mobile Phone
Email
*
example@example.com
Occupation
*
Current Job. Type 'child' if the patient is under 18.
Have you seen any doctor here in New Zealand
Please Select
Country of Birth
*
Please attach a copy of the photo page of your passport.
*
Browse Files
Cancel
of
Passport Number
*
Passport Issuing Country
*
NZHR/NHER number
Health Case Identifier Number
Passport Issue Date
*
-
Month
-
Day
Year
Date
Passport Expiry Date
*
-
Month
-
Day
Year
Date
Visa Category
*
Please Select
Visitor
Residency
Student
Work to Residence
Humanitarian
Skilled / Business Worker
Investor
Pacific Categories
Worker with job offer
Worker without job offer
Other
If you answered 'other' to the above please type in your visa category.
How long do you intend to stay in New Zealand?
*
Please Select
Less than 6 months
6 - 12 months
12 - 24 months
More than 24 months
What examination do you require?
*
Please Select
General Medical NO X-Ray
Limited Medical NO X-Ray
X-Ray ONLY
General Medical WITH X-Ray
Limited Medical WITH X-RAY
Supplementary Report
Have you:
tested postive for COVID-19 in the last week
in the past 14 days had someone in your household tested positive for COVID-19 or been instructed to self-isolate
been experiencing cold or flu symptoms that have RECENTLY started these include: cough, runny nose, sore throat, fever, lost of taste and smell
Covid symptoms or house hold contacts?
*
YES
NO
If you are submitting this form on behalf of someone else, please state your name and relationship to the patient.
Submit
Should be Empty: