Level 1, 61 Taranaki Street, Te Aro, Wellington
E reception@wellingtonradiology.co.nz P 04 801 8527
Patient Name *
Preferred Name *
Gender *
Date of Birth *
NHI Number *
Phone Number *
Address *
Postcode *
Date of Attention * Has the Patient had a previous scan: Y / N / NA
Clinical details For Pregnancy/Female Scans
LMP
EDD
ACC claim number Y/N
CSC card
Quintile
Other information
Special accommodation request (difficult patient, psychological/behavioural information)
Name
Position GPMidwifePhysiotherapistSpecialistother
Practice
Contact No
Email
EDI
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