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Immunisation Reminder Email
Please enter parent & child's details
Your Information
*
First Name:
*
Last Name:
*
Email Address:
Child’s Information
*
First Name:
*
Date of Birth:
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Clinic Information
*
Name:
*
Phone Number:
Please note:
- All information is confidential and will only be used to send appointment reminders on behalf of the Doctor's Surgery who submits the Patient's details and to record the number of Free Goodies Packs being distributed.
- You need to submit an email address to enable us to send out the free email reminders on your behalf.
If you have any queries regarding this form:
Please do not hesitate to contact:
Kevin D'Ambros-Smith
Phone: 09 444 2634
Email:
kevin@nappies.co.nz
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