New Patient Form Please complete this form before your first appointment. Your appointment date * MM DD YYYY Title Mr Ms Mrs Miss Master Dr Prof Name * First Name Last Name Preferred name (if different from first name) Date of birth * MM DD YYYY Gender Male Female Gender neutral / non-binary NHI (hospital) number (if known) Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Postal address and postcode (if different from street address) Next of kin (and relationship) Next of kin phone number / email Occupation Family doctor (GP) * GP practice name and address * Preferred pharmacy * Medical insurance * Yes No Medical insurance company name and membership number Current or past medical problems and operations * Current medications * Medication allergies * How did you hear about us? * GP / Specialist Friend / Family Website / Search Engine Other (please specify below) Other source of finding us Tick the category that best applies * NZ or Australian citizen or permanent resident Resident class visa or work visa valid for 2 years or more Neither Consent to AI scribe * Yes No Thank you!