HHL Registration form Welcome to Registration for NZDSOS's Health Help Line If you have any difficulties filling out this form please contact the Health Help Line directly on: [email protected] 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 If you are having trouble with the date of birth, please type it out here in long form. Please upload a photo or PDF of your passport page (with visa if applicable) or birth certificate. This is required for Ministry of Health access to blood tests and subsidised medications where appropriate. If you are having trouble with this please contact the NZDSOS Health Helpline or fill out the contact form on the NZDSOS website. Choose File Email Address Phone Number (preferably mobile) Alternative Phone Number Address Line 1 Address Line 2 City Post Code Country Please click on New Zealand to bring up other country options.AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweName of next of kin to contact in case of emergency Phone Number of next of kin to contact in case of emergency Email of next of kin to contact in case of emergency Do you give us consent to contact your usual GP about changes in treatment and other relevant health information? - Select -YesNoUsual GP Name and Clinic Usual Pharmacy Name and Address Please let us know what you want help with e.g. vaccine injury, general practice services. 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 for consultation: $95 for 20 minutes Doctor fee for answering a query through your patient portal (Manage My Health): $20 Please note the clinic is completely private with no government funding. For a full list of fees please see here. I have read and agree to the Rights, Privacy and Consent commitments. I have read and agree to the Terms and Conditions and Privacy PolicySubmit
