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Personal information

First Name *

Last Name *

Gender *

Male Female Gender Diverse

Mobile Phone *

Email Address *

Date of Birth *

Country of Birth *

Place of Birth *

Ethnicity *

Māori New Zealand European Samoan Cook Island Māori Tongan Niuean Chinese Indian Other

Street Address *

Suburb *

City *

Postcode *

Authority

Is the patient 16 or over? *

Yes No

Patient Survey

Do you want to participate in Patient Surveys?
(Optional)

Yes No

Proof of Eligibility

This must be a scan or photo (taken on your phone is fine) of the the front two pages of your passport for New Zealand citizens PLUS a copy of the relevant visa for non NZ citizens. Birth certificates are acceptable for people who have never been issued a passport.

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