Request an appointment

To request an appointment online please complete the form below

We will endeavour to contact you as soon as possible in relation to your preferred time.

As you are probably aware its not always possible to get the exact time you request but we will do our best to fit you in.
 
If you have a preferred location and provider please select these also.

Full Name:	*required
Date of Birth	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 JAN FEB MARCH APRIL MAY JUNE JULY AUGUST SEPT OCT NOV DEC 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 *required
Email:	*required
Phone:	* required
Preferred Day or Date
Preferred Time	(Please give a range of times that suit)
Preferred Location	PS @ Colombo Street	Preferred Provider          Please Select Graeme Nuttridge Marie Nuttridge Francesca Faulkner No Preference
	PS @ Cityfitness Moorhouse	Preferred Provider          Please Select Graeme Nuttridge Blair Jarratt Ben McIvor Broderick Lin Simon Cutler No Preference
	PS @ Pioneer	Preferred Provider          Please Select Lucy Whiteside Francesca Faulkner Mitch Hunter No Preference
	PS @ Moorhouse Medical	Preferred Provider          Please Select Dr Mark Laslett Broderick Lin No Preference
	PS @ Northwood	Preferred Provider          Please Select Graeme Nuttridge Lidia Belles Escrig Simon Cutler No Preference
	PS @ Merivale	Preferred Provider         Please Select Ben McIvor
	PS @ Kaiapoi	Preferred Provider          Please Select Colin Hancock Stuart Knappstein No Preference
	PS @ Riccarton	Preferred Provider         Please Select Graeme Nuttridge Aaron Cuniffee Becs Adams No Preference
	PS @ Clarendon	Preferred Provider         Please Select Stuart Knappstein Graeme Nuttridge
ACC Related	Yes No Unsure
New Patient or Returning Patient	New Patient Returning Patient	New Injury or Return Visit         New Injury Return Visit
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