Casual Register Form Caring Clinic Doctors v1.3c

Caring Clinic Doctors Casual Form

Level 8, 175 Queen Street, Auckland 1010 Ph09 2222577 Fax09 2222575 EDI:caring8q GP2GP: Dr R Sim MCNZ38537
Please fill in the form in English. 请用英语填完表格。

If you believe you are eligible for NZ healthcare and want to enrol, please click here instead.如果您认为自己符合新西兰医疗注册条件，请按此注册怀爱诊所。
Name 名：*

Title 称呼First Name 名Last Name 姓
DOB 出生日期：*

DayMonthYear
Date 出生日期（日-月-年）
Gender 性别：*

Male男Female女Other
Ethnicity Details 你属于哪个种族？*

New Zealand EuropeanChinese 中国人/华人MaoriSamoanCook Island MaoriTonganNiueanIndianOther
Mobile 手机：*
phone number
Email 电子邮箱：*
example@example.com
NHI number 新西兰医疗号 (如果知道）：
NHI =national health index number
Address 住址*

street address

Street Address Line 2

City 城市State / Province

Postal / Zip CodeCountry 国家
Emergency Contact Name 紧急联系人：*
full name please 全名
Contact Phone number 电话：*
ideally phone number, otherwise email/others 邮箱也可以
Contact Relationship 关系：*
eg partner/ family/ friend 家人/朋友等等
Please upload a copy of your photo ID (i.e. Passport/ Driver license)- suggestion: scan and add, or take a photo and attach. 请上传带相件的证明文件：（护照照片页/ID/等等）

Browse Files
can upload more than one files (including jpeg/ pdf etc) Cancelof
Signature 签名：*

Clear
sign above the line 线上签名
If signed by AUTHORITY 若授权人填表，请打勾：

open up if clicked not self signed
Name of authority 授权人：

Title 称呼First Name 名Last Name 姓
Relationship to patient 亲属关系：
eg. parents/ wife/ husband/ guardian etc
Phone Number 电话联系

Area CodePhone Number

end of authority info
Should be Empty:

Caring Clinic Doctors Casual Form