Surgical | The Women's Clinic

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What Manawatū, Horowhenua, Tararua town do you live in?(Required)

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What Southland town do you live in?(Required)

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What town do you live in?

Address Details

Street Address Address Line 2 City ZIP / Postal Code

Ethnicity/Nationality

What is your residency status in New Zealand?

What visa do you hold?

Do you need support from a counsellor?

Do you know the date of your last period?(Required)

Date of period if known

Have you had a blood test?(Required)

Have you had a blood test?*

Yes

Where did you get your blood test done?

Please specify the hospital where you had your blood test.

Do you have the results of your blood test?

Yes

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Max. file size: 100 MB.

Have you had a scan?(Required)

Have you had a scan? *

Yes

Where did you get your scan done?

Do you have the results of your scan?

Yes

Upload scan results:

Max. file size: 100 MB.

Date of birth(Required)

Full Legal Name(Required)

(as recorded on your birth certificate or passport)

Preferred Name

(if applicable)

Phone Number(Required)

Is it safe to call?(Required)

Is it safe to call?*

Yes

Are you concealing your procedure from family/friends?(Required)

Are you concealing your procedure from family/friends?*

Yes

Is it safe to text?(Required)

Is it safe to text?*

Yes

Email Address(Required)

Enter Email Confirm Email

Is it safe to email you?(Required)

Is it safe to email you?*

Yes

Is English your first language?(Required)

Is English your first language? *

Yes

Do you need a translator?

Do you need a translator? *

Yes

What language do you need?(Required)

Are you enrolled with a GP?(Required)

Are you enrolled with a GP?*

Yes

Name of GP(Required)

Name of Practice(Required)

Would you like a summary letter sent to your GP?

Would you like a summary letter sent to your GP? *

Yes

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