Casual Form - IntelliMed

Casual Form

PERSONAL DETAILS

NHI Number (if known):

Title:

Given Name:

Middle Name(s):

Family Name:

Preferred Names:

Assigned Sex (at Birth):

Gender:

Please state Another Gender:

Date of Birth:

Country of Birth:

Place of Birth:

Ethnicity:

Please state Other Ethnicity:

RESIDENTIAL ADDRESS

Street Number and Name:

Suburb:

Town / City:

Postcode:

My residential and postal addresses are the same

POSTAL ADDRESS

Street Number and Name:

Suburb:

Town / City:

Postcode:

CONTACT DETAILS

Mobile Phone:

Work Phone:

Home Phone:

Email Address:

Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Contact Relationship:

Emergency Contact Phone:

Do you have a Community Service Card or High Use Health Card?

Yes

No

Preferred Practice:

Do you have a GP?

Yes

No

I do NOT want my notes to go to my GP

If your notes are not sent to your GP, they cannot follow up on your visit today.

Name of Current Doctor/Practice:

Location of Current Doctor/Practice:

Are you a resident of New Zealand?

Yes

No

Did you have a new accident?

Yes

No

Please sign below (clear signature)

Authority:

Parent/Guardian Full Name:

Relationship:

Contact Phone:

Please search GP name or medical centre:

No matching GP/medical centre found. Try searching with just the first word of the medical centre. Or, use