Dr. W. P. Ciszak Medical Services Inc.

Registration for New Zealand medical exam

Please send us a completed form before making an appointment.
A separate form is required for each family member.

Certificate required
Please select a valid item.
Given names (First name) Name is required.Full given names required.
FAMILY NAME (Last name) Last name required.Full last name required.
Gender Please select a valid item.
Date of Birth Birth date is required.Format dd/mm/yyyy. Date format: dd/mm/yyyy
Country of birth Country of birth missing.Minimum number of characters not met.
Address - Street Address is required.Does not look valid.
Address - City City is missing.Does not look valid.
Address - Prov or State A value is required.Two characters required.Two letters only.
Address - Postal Code Postal code or zipcode required.Does not look valid.
Telephone Phone number required.Invalid format - use 0000000000.Must have 10 digits.Must have 10 digits.
Email Enter Email address.Enter Email address or "none".Invalid format.
ID document type
Please select a valid item.
ID document Number ID number required.Does not look valid.
ID issuing Country Issuing country is missing.Does not look valid.
ID document issue date Date required.Format dd/mm/yyyy.Date format: dd/mm/yyyy
ID document expiry date Date required.Format dd/mm/yyyy.Date format: dd/mm/yyyy
NZER number (if available)
Have you had an examination
in our office before?
Make a selection

I agree to the Terms and Conditions
Check the box if you agree

Please double-check your entries before submitting!
Errors will be difficult to correct after your file is created.

We will use email if we cannot reach you by phone. Personal email address is preferred

Canadian or US number only. Local phone number preferred. This is needed to contact you if additional tests are required or other problems occur,

Format: 10 digits without spaces or hyphens.

Local address is preferred, even if it is not permanent.

Date format: dd/mm/yyyy
(numeric day, month and full year separated by periods)

A valid passport is always preferred. A copy of the passport is acceptable but then you will also have to show us another picture ID. A passport that is expired for less than one year may also be acceptable.

If you have no passport, a national ID card or a Canadian driver's license may be acceptable.

INZ Reference Number

If you have already applied for NZ immigration you probably have this number.

If you are doing an "upfront" medical you probably do not have this numbert. If you don't, leave this box blank.

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