Patient Registration Form

Patient Registration Form

PATIENT DETAILS

MrMrsMissMsDr

Surname

First Name

Middle Name

Preferred Name

Date of Birth

Gender

MaleFemaleGender Diverse

NHI (Office Use Only)

PATIENT CONTACT DETAILS

Home Phone

Mobile Phone

Work Phone

Residential Address

Street addressStreet address line 2

Suburb

City

Postcode

Country

ETHNICITY & RESIDENTIAL DETAILS

Which ethnic group(s) do you belong to?

New Zealand EuropeanMāoriSamoanCook Island MāoriTonganNiueanChineseIndianDutchJapaneseTokelauan

Country of Birth

Place of Birth

If you are not born in New Zealand, are you a New Zealand resident?

YesNo

Are you a refugee?

YesNo

Are you on a working visa?

YesNo

EMERGENCY CONTACT DETAILS

Name

Residential Address

Street addressStreet address line 2

Suburb

City

Postcode

Country

Postcode

Mobile Phone

Work Phone

NEXT OF KIN CONTACT DETAILS

Is the next of Kin same as your emergency (if yes, you do not need to fill this section)

YesNo

Next of Kin - Name

Next of kin - Email

Next of kin - Relationship

ParentsSpouse/ PartnerChildrenFriendOther

Next of kin Home Phone

Next of kin - Mobile Phone

Best way to contact your next of Kin

Home PhMobile PhWork Ph

REFERRING DOCTOR TO US

Referring Doctor’s Name

Address

Family Doctor/ Regular General Practitioner Name (if different to referring doctor)

Address

COMMUNITY SERVICES INFORMATION

Community Services Card No. (not client number)

Expiry Date

High User Card No.

Expiry Date

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

Draw signature|Type signatureClear

Today's Date

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