Patient Enrolment Waiting List 家庭医生注册等候表
Please be aware that submitting this form does not mean you are enrolled.请注意提交此表格不代表你已經注册。
Today's Date DD/MM/YYYY 今天日期
/
Day
/
Month
Year
Date
Name 姓名
First Name 名
Last Name 姓
Date of Birth DD/MM/YYYY 出生日期
/
Day
/
Month
Year
Date
Gender 性別
Male
Female
Others
NHI number (if known) 新西兰医疗号（如果知道）
Mobile no 手机号码
Email 电子邮箱
Do you have family member who is already our enrolled patient 您是否有家人已经是我们登记的患者
Yes 是
No 否
Name of the enrolled family member 已登记家人的姓名
First Name 名
Last Name 姓
Relationship with you 他跟你的关系
Date of Birth of the enrolled family member DD/MM/YYYY 已登记家人的出生日期
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Day
/
Month
Year
Date
Submit
Should be Empty: