Application Form for Requestors
Doctor, Clinician, Midwife, Smeartaker
Smear taker **
* NZMC # / Midwife or Smeartaker? - ID please
Duration at practise
Less than 1 month
More than 1 month
Are you working at another practise?
Yes * Please list those practises below.
* Other practises
AFTER HOURS #
DHB (District Health Board) REGION
Pathlab collects this information to facilitate the sending of laboratory results and related health information. Pathlab will also share this information with other organisations within the health sector for clinical purposes.
I hereby authorise Pathlab to use the information herein as they require in the receipt and delivery of test results.
I confirm that all information contained in this form is correct.
Address Line 2
City / Postal Code