Immigration Medical Register Form Caring Clinic Doctors v1.3e

To register for a NZ immigration medical please fill out the form below.
Name (as it appears on your passport) ：

Title First Name Last Name
DOB ：

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Date today

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Age
Mobile ：
phone number
Email：
example@example.com
Gender ：

Other
Are you pregnant?
Ethnicity Details

Other
Country of birth:
Address (NZ residential Address) :

street address

Street Address Line 2

City State / Province

Postal / Zip CodeCountry
Emergency contact's name:
name of next of kin/ emergency contact
Contact: phone number:
ideally phone nubmer, otherwise email/ others ok
Contact: Relationship:
eg Family/ friend/ partner/etc
Current Visa Status:

Other
Current Visa Status:

Other
What Visa are you applying for (proposed visa application type):

Other
What Visa are you applying for (proposed visa application type):

Other
How long are you intending to stay in New Zealand for this time?

Other
How long are you intending to stay in New Zealand for this time?

Other
Please upload a copy of your Passport here:

Browse Files
can upload more than one files (including jpeg/ pdf etc) Cancelof
Please upload a copy of immigration requirement Letter/ Email screenshot here:

Browse Files
can upload more than one files (including jpeg/ pdf etc) Cancelof
Do you have any medical conditions/ previous medical issues ? (can briefly enter here eg hypertension, diabetes, depression)
This just help us prepare certain extra check up if need be for you,
Have you read the eMedical Client Declaration ?
Signature ：

sign above the line
If signed by AUTHORITY ：
- Name of Authority：
  
  Title First Name Last Name
- Relationship to patient：
  eg. parents/ wife/ husband/ guardian etc
- Basis of Authority:
  why patient can't sign
- Phone Number:
  
  Area CodePhone Number
- Should be Empty: