Registration Form

Registration and Appointment Booking – Genetic Counsellor

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Step 1: Please complete the form bellow *Minimum information required
First Name*
Surname*
Select Gender
Date*
Ethnicity
Country of Birth*
New Zealand Resident?*
Primary contact number*
*Email Address*
Mobile Phone
Work Phone
Preferred method of contact
Street Address*
Suburb
City
Postcode
Postal address (if different from above)
NHI
Insurance company
Emergency contact
Phone number
Relationship to you
Have you previously seen a Genetics Counsellor or attended a Genetics Clinic?
Counsellors name / Clinic name (if known)
GP Name*
GP Practice Name*
Referring Dr (provide if you have a referral)
Referring Dr’s phone number
Reason for seeing us?
File Upload
Drop files here or
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Step 2: Select appointment type (if you haven’t seen our genetic counsellor before, select “Initial Consult”)

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Step 3: Select "Any" practitioner or name of genetic counsellor (“Any” will show the next appointment times)

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Step 4: Select Date and Time for your appointment. Select "Name" of practitioner if more then one is available.
Select a service

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Sorry, there are no appointments available this month.

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Afternoon

Evening

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Step 5: Review appoinment summary (Adjust if required)

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Appointment summary

Location

New Zealand Family Cancer Service
Nationwide Telehealth Service
via Zoom.us

Service

Practitioner

Date

Time

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Step 6: Please check the boxes accordingly, then press submit button bellow (an appoinment confirmation will be emailed to you)

- Do you have a Video-chat capable device?
  I confirm that I have a camera on my device for video appointments eg smartphone camera or computer.
*
- Read Our Fee Schedule
  I have read and understand New Zealand Family Cancer Service’s fee schedule
*
- Agree to Terms of Trade and Privacy Policy
  After checking this box, you will be redirected to a new page where you will be asked to read and confirm acceptance to our Terms of Trade and Privacy Policy