Vaccine & Mask Certificate Application

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

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?

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.

Welcome to the NZDSOS Online Clinic Patient Registration for Vaccine Certificate Assessments

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