Welcome to the NZDSOS Online Clinic Patient Registration for Vaccine Certificate Assessments The Clinicians at NZDSOS assess each individual's health information in relation to what is known about the Covid-19 injections. Although there is a lack of predictability about whether authorities or employers will accept the clinical judgment of trained doctors, our assessments are our clinical judgment and may be able to be used in legal proceedings. 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. The certificate is an official document that certifies that you have been assessed by a doctor. This doesn't guarantee it will be accepted/recognised by whomever you present it to - that is their choice/risk. 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 Select Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belau Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Saint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda São Tomé and Príncipe Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (Dutch part) Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia/Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (UK) United States (US) United States (US) Minor Outlying Islands United States (US) Virgin Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Next of kin to contact in case of emergency: (name, address, phone) Usual GP Name and Clinic Is your job affected by the vaccine mandate? No Yes Please briefly explain how you intend to use the exemption Urgency Semi Urgent Super Urgent Can wait a week or so Please let us know what day and time suits for your appointment 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 currently taking 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. Submit