Your Health Centre Papatoetoe Limited
Immigration Medical Booking Form
How did you hear about us?
*
Family / Friend
Website
Google Ad
Neighbourly
Advertisement Sign/Flyer
Tik Tok
Instagram
Facebook
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
*
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 Referral
Limited Medical NO X-Ray Referral
X-Ray Referral ONLY
General Medical WITH X-Ray Referral
Limited Medical WITH X-RAY Referral
Supplementary Report
If you are submitting this form on behalf of someone else, please state your name and relationship to the patient.
Submit
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