Immigration Medical Health Questionnaire

Immigration Medical Questionnaire

Please complete this health questionnaire. A form is required for each individual including children that will undergo the medical.
1: Personal Details
Full name (as it appears on your passport)*

Given Name(s)Last name
Identity document number (e.g. passport number)
Country of passport
Date of issue

MonthDayYear
Date of expiry

MonthDayYear
Address*

Street Address, Suburb

Street Address Line 2

City, Postal CodeState / Province

Postal Code
Contact number*
Email*
Date of birth*

DayMonthYear
NHI number (if known)
Gender*

MaleFemaleGender Diverse
Primary ethnicity*
Other ethnicity*
NZER or NZHR number (if known)

2: Type of Medical Required
What type of medical is required?

General MedicalGeneral Medical with XRayLimited MedicalLimited Medical with XRay
GENERAL MEDICAL Fees:

Adults age 15+: $385

Children age 0-14: $175
GENERAL MEDICAL W/ XRAY Fees:

Adults age 15+: $550
($360 to Phoenix Healthcare + $190 to Pacific Radiology)

Children age 0-14: $330
($140 to Phoenix Healthcare + $190 to Pacific Radiology)
LIMITED MEDICAL Fees:

Adults age 15+: $250
LIMITED MEDICAL W/ XRAY Fees:

Adults age 15+: $410
($220 to Phoenix Healthcare + $190 to Pacific Radiology)
If you are unsure about the type of medical examination required, please contact Immigration New Zealand for assistance. We are unable to provide advice regarding this.

Immigration Medical Questionnaire