INFO:

Patient admission form IMPORTANT Please send this completed form to the Hospital where you will have your procedure/surgery. PERSONAL AND ADMINISTRATION DETAILS Mr Surname family name First name s Date of birth Mrs Ms Miss Mstr Dr Preferred name d / m Gender Male y Female NHI Residential address Postal address Email address Telephone Home New Zealand resident Yes Business Mobile No Ethnicity European / Maori / Pacific Island / Asian / Middle Eastern / Latin American / African / Other Please...