Employee Request for Medical Information

Please complete electronically & allow two weeks for processing. If you have any difficulty completing this form, please email occupational.nurse@ccdhb.org.nz.

General information – please complete ALL sections

Full name *
Previous name(s) (if applicable)
Date of birth *
NHI number (if known)
Dates of Employment at CCDHB *
Email address – for return of information *
Information requested
Vaccination record *
Blood tests *
Additional comments 0/500 Words

Last updated 8 February 2023.

Employee Request for Medical Information

General information – please complete ALL sections

Information requested