First name
*
Surname (family name)
*
Date of birth
*
Your phone/mobile number
*
Email Address
*
Medical insurance?
*
No
Yes
Southern Cross member?
*
No
Yes
Southern Cross policy number
*
nib member?
*
No
Yes
nib policy number
*
What is the name of your medical insurer?
*
Preferred day and time
*
Remuera Monday (8am - 11:30am)
Remuera Tuesday (8am - 5pm)
Remuera Wednesday (8:30am - 11:30am)
No preference
Do you have a referral?
*
No
Yes
Click to attach referral
Max file size 25Mb
Attach a scanned copy of your referral letter
Reason for visit (may be seen by reception staff)
*
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