Hepatitis Foundation

Pre-screening Form

Hepatitis Foundation Referral Form

Patient Name(Required)

(As shown on identification document e.g. Driver's License, Passport)

Patient Contact Number(Required)

(Your best contact number)

Patient Email Address(Required)

(Your best contact email)

Referring Person

(Nurse, doctor, or clinic name, if applicable)

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I understand that by submitting this form, the patient is/I am aware that NZCR will contact them/me and authorise their/my contact details to be shared. All information provided is confidential and will not be given or sold to any other agency without prior consent. For more information, please refer to the Privacy Policy

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NZCR Advancing global health

About NZCR

New Zealand Clinical Research (NZCR) provides state of the art research facilities and the expertise to conduct complex early phase clinical research in healthy participant and patient populations.

Auckland

Grd floor, 3 Ferncroft St, Grafton
Auckland 1010
New Zealand
0800 788 3437
+64 9 373 3474

Christchurch

Level 3, 264 Antigua St
Christchurch 8011
New Zealand
0800 862 278
+64 3 372 9477

Hamilton

Unit 1B/300 Grey Street
Hamilton East, Hamilton 3216
New Zealand
0800 788 3437

Wellington

Level 4 / 108 The Terrace
Wellington Central,
Wellington 6011
0800 862 278