panel3 panel5 Policy Information Hidden fields Information GP Telehealth Appointment PLEASE COMPLETE AND SUBMIT THIS FORM All fields marked with an asterisk (*) are required. If a question does not apply, enter 'N/A' as your response. Please select your preferred date and appointment time below. Complete the application form and attach. Your organisation may require you to submit your own referral form, please check you intranet regarding this process. PLEASE NOTE: A team member from NZ Provide will confirm your appointment day and time. FIRST NAME* Surname* Contact Number* Email* GENDER* Male Female Undefined Preferred Contact Method* Please select how you would like to be contacted. Email Mobile EMPLOYER MANAGER'S NAME MANAGER'S EMAIL* I WOULD LIKE TO SET AN APPOINTMENT FOR: 9:00 AM - 10:00 AM 10:00 AM - 11:00 AM 11:00 AM - 12:00 PM 1:00 PM - 2:00 PM 2:00 PM - 3:00 PM 3:00 PM - 4:00 PM 4:00 PM - 5:00 PM File Attachment Attach Submit Note: Your organisation may require you to submit your own referral form, please check you intranet regarding this process.