Contact Form

1
Name* I need this information. Please complete this field. Thank you.Please indicate your first and last names.
First Name
Last Name
2
Email* I need this information. Please complete this field. Thank you.Emailing is my preferred mean of communication. The email address that you will insert below will be the email address that I will use to revert to you. This is also the email address to which you will receive your completed form once it is submitted.
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code?or
Receiving the email may take a few minutes, thank you for your patience!
3
Phone* I need this information. Please complete this field. Thank you.Please indicate the New Zealand mobile phone number on which you want to receive texts/SMS or be called back.
NZ Code
Prefix
Number
4
Reason for contacting* I need this information. Please complete this field. Thank you.The reason for which you are contacting me is
to solicit an appointment for you
to solicit an appointment for someone else (including a referral)
to request general information
for another reason
5
Age* I need this information. Please complete this field. Thank you.Please indicate if the patient for whom you solicit an appointment is at least 16 years old.
Yes, the patient is 16 years old or more
No, the patient is less than 16 years old
6
Patient* I need this information. Please complete this field. Thank you.Please indicate the patient's first and last names.
First Name
Last Name
7
Relationship* I need this information. Please complete this field. Thank you.Please indicate your relationship with the patient = you are the [select] of the patient. If you select "Other", please complete field with appropriate relationship.
Mother
Father
Caregiver
Spouse/Partner
Daughter
Son
Sister
Brother
GP
Therapist
Guardian
Other
8
Reason for appointment* I need this information. Please complete this field. Thank you.Please explain in a few sentences and with your own words the reason for which you solicit an appointment for you or for someone else.
9
Address* I need this information. Please complete this field. Thank you.Please indicate the patient's suburb/city of usual residence.
Suburb, City
10
General information* I need this information. Please complete this field. Thank you.Please specify the topic on which you seek general information from me.
11
Other reason* I need this information. Please complete this field. Thank you.Please specify the reason for which you are contacting me.
12
I am sorry. I only provide care and treatment for adults and adolescents aged 16 or more. Unfortunately the patient for whom you solicit my services is too young for my practice. Depending on the reasons for which you seek an appointment, I may be able to refer a colleague who could be of assistance. If you are interested by such a referral, please indicate the reasons for which you seek an appointment in the next box ("Comments").
13
File UploadPlease feel free to upload here any document(s) that you deem relevant for me to consider. Example: if you have a referral from your GP, upload it here.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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CommentsPlease feel free to add here any comment or question you may have.
0/200
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