NZDSOS Online Clinic Application | NZ Doctors Speaking Out With Science

Welcome to the NZDSOS Online Clinic Patient Registration

I confirm the details I give are true and correct. I have disclosed my true identity and the true purpose of my consultation and I am acting in my capacity as a private citizen. I realise that if I give false information before or during this consultation then no information from before or during this consultation can be used in any way. I understand that my doctor will keep the contents of my consultation confidential and that I agree to do the same.

Your First Name

Your Last Name

Your Preferred Name

Your Date of Birth

Email Address

Phone Number (preferably mobile)

Alternative Phone Number

Address Line 1

Address Line 2

City

Post Code

Country

Next of kin to contact in case of emergency: (name, address, phone)

Usual GP Name and Clinic

Usual Pharmacy Name and Address

Urgency

Semi urgent

Super urgent

Can wait a week or so

Please let us know what day and time suits for your appointment

Please advise what you are seeking help with?

Have you ever had adverse reactions (side effects or allergy) to medication? If so, please describe.

Do you have any medical conditions that you are currently under treatment for?

Are you currently using medication? If so, please list:

Are you taking any supplements? If so, please list:

I understand the fees for the NZDSOS clinic are:

Nurse fee: koha (we suggest $30.00)
Doctor fee: $75 for 15 minutes

Please note the clinic is completely private with no government funding. We pay our staff from donations and consultation fees.

I have read and agree to the Rights, Privacy and Consent commitments.