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Your name (First and Surname)
*
Date of birth
*
Your phone/mobile number
*
Email Address
*
Medical insurance?
*
No
Yes
Southern Cross member?
*
No
Yes
Southern Cross policy number
*
nib member?
*
No
Yes
nib policy number
*
What is the name of your medical insurer?
*
Preferred Dermatologist
*
No preference
Dr Todd Gunson
Dr Paul Le Grice
Dr Fergus Oliver
Dr Denesh Patel
Dr Chin-Yun Lin
Dr Bob Chan
Preferred day and/or time (Mon to Fri, 8am to 5pm)
Preferred location and day
*
Botany Monday (8am - 5pm)
Remuera Tuesday (8am - 5 pm)
Remuera Wednesday (8:30am - 11:30am)
No preference
Preferred location and day
*
Remuera Monday (9am - 4pm)
Remuera Tuesday (8:30am - 4pm)
Remuera Thursday (8:30am - 4:30pm)
Remuera Friday (9am - 2pm)
No preference
Preferred location and day
*
Remuera Monday (8am - 4:45pm)
Remuera Wednesday (8:15am - 3:45pm)
Remuera Thursday (9:45am - 12pm or 4pm - 4:45pm)
No preference
Preferred location and day
*
Remuera Wednesday (9:15am - 5pm)
Remuera alternate Thursdays (9:15am - 5pm)
Remuera Friday (8am - 11:45am)
Pukekohe alternate Thursdays (8:30am - 3:30am)
No preference
Preferred location and day
*
Remuera Tuesday (8:30am - 12:00pm)
Ormiston Wednesday (8:45am - 4:15pm)
Remuera Thursday (8:30am - 3:30pm)
Remuera Friday (8:30am - 3:30pm)
No preference
Preferred location and day
*
Remuera Tuesday (2:00pm - 6:00pm)
Remuera Thursday (8:00am - 5:00pm)
Remuera Friday (8:00am - 12:30pm)
No preference
Do you have a referral?
*
No
Yes
Click to attach referral
Max file size 25Mb
Attach a scanned copy of your referral letter
Reason for visit (may be seen by reception staff)
*
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