First name *

Surname (family name) *

Date of birth *

Your phone/mobile number *

Email Address *

Medical insurance? *

Southern Cross member? *

Southern Cross policy number *

nib member? *

nib policy number *

What is the name of your medical insurer? *

Preferred day and/or time (Mon to Fri, 8am to 5pm)

Preferred day for Dr Gunson *

Preferred location and day for Dr Oliver *

Preferred location and day for Dr Patel *

Remuera Tuesday (8am - 3pm)
Remuera alternate Thursdays (9:15am - 3:15pm)
Remuera Friday (8am - 11:45am)
Pukekohe alternate Thursdays (8am - 2:45pm)
No preference

Preferred location and day for Dr Lin *

Preferred location and day for Dr Chan *

Preferred location and day for Dr Lawrence *

Preferred day for Dr Chung *

Preferred day for Dr Liu *

Do you have a referral? *

Click to attach referralMax file size 50Mb

Attach a scanned copy of your referral letter

Reason for visit (may be seen by reception staff) *

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