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。
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
/
Day
/
Month
Year
Date
Submit
Should be Empty: