04 384 4315
Call us today
Level 2 / 61 Taranaki Street
Home
About us
Pricing
Practice policies
Links
Our Team
Services Offered
Manage my health
Contact us
Call Port Nicholson Medical 04-384 4315 for an appointment
Port Nicholson Medical
Level 2
61 Taranaki Street
Te Aro
Wellington, 6011
Phone: 04 384 4315
Email: reception@portnicmed.co.nz
Opening Hours
Monday: 8am - 5:00pm
Tuesday: 8am - 5:00pm
Wednesday: 8am - 5:00pm
Thursday: 8am - 5:00pm
Friday: 8am - 4:30pm
Weekends & Public Holidays : Closed
Contact Form
*
Indicates required field
Name
*
First
Last
[object Object]
Phone Number
*
Message / Comments
*
Email
*
Send
New Patient Application
If you are interested in becoming a patient at Port Nicholson Medical Centre please fill out this application form and we will assess our capacity to take you on as a new patient.
Please note this is not an enrolment form
, if we are able to take you on as a new patient we will be in contact and will send you an enrolment pack to complete.
*
Indicates required field
Name
*
First
Last
Date of birth
*
Email
*
Phone number
*
Gender
*
Do you have a current GP in Wellington?
*
Yes
No
What is your current residency status?
*
Are you a current NZ citizen or have residency in NZ? If not where do you have residency?
What is your ethnicity?
*
What is your current smoking status?
*
Current smoker
Ex smoker
Never smoked
How many standard drinks do you typically consume per week?
*
1 small glass of wine OR 330ml can/bottle of beer OR 1 nip of spirits = 1 standard drink
Are you on any regular medications?
*
Yes
No
If yes, please list with doses and frequency if possible
*
Do you have an allergy to any medication or significant reactions to any other substance?
*
Yes
No
If yes, please list these medications
*
Past medical history: please give a brief summary of any long-term or serious health conditions you have or have had including major surgeries
*
Family history: do any of your immediate family (parents and siblings) have any serious health conditions including diabetes, heart disease or any type of cancer? Please give details
*
Any other queries or information you would like to include?
*
Submit