Cambridge Migration Medical Services Front Sheet by fDQ7Zq

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									                                       Cambridge Migration Medical Services
                               Dr. F. O’Kelly - Medical Director M.B.,B.Ch.,B.A.O.,B.Sc

Please print and complete for each applicant having a New Zealand Medical
___________________________________________________________________________

Name                                     Date of birth          Age
___________________________________________________________________________

Address
___________________________________________________________________________

Phone Number
___________________________________________________________________________

E-mail Address

HIV Consent (for applicants over age of 15 years)

I hereby give my consent for blood to be taken for the HIV test and to the release of results
to The New Zealand Immigration Services. I confirm I have read the pre-test counselling.

Signed:                                                                         Date:

If there is a positive result, you will be contacted directly by Dr O’Kelly.
To be completed by doctor:


Weight____________ kg                               BMI ________

Height ____________ cm

Waist Circumference __________ cm Head Circumference __________ cm

Blood Pressure Readings (1) _____________ mmHg                                 (2) _____________mmHg

Pulse Rate __________ bpm reg / irreg

Urine Test             Blood pos / neg                    Sugar pos / neg       Protein pos / neg

Vision Test (R) _________ corrected / uncorrected (L) _________corrected / uncorrected



Cambridge Migration Medical Services
Dr Frank O’Kelly
October 2010

								
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