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Title*
Mr
Mrs
Ms
Miss
Problem/Complaint
Preferred clinic location
North Shore Clinic
Remuera Clinic
Manukau Clinic
New Lynn Clinic
Referred to*
1st available
Dr William Cunningham
Prof Helen Danesh-Meyer
Dr Simon Dean
Dr Peter Hadden
Dr Nick Mantell
Prof Charles McGhee
Dr Jay Meyer
Dr Graham Reeves
Dr Peter Ring
Dr Shanu Subbiah
Dr Adam Watson
Thank you for seeing my patient for assessment of
Cataract
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Neuro-ophth’
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Yes, for date
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Note: None of this information will be passed on to any other party. *Denotes mandatory fields.
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