Nelson Marlborough community oral health services pre-enrolment form

Use this form to pre-enrol for community oral health services in the Nelson, Tasman and Marlborough regions.

Fields with an asterisk (*) are required.

Name of person being enrolled

Date of birth

Closest school

Your address

Phone number

Parent or caregiver name

Name of Wellchild | Tamariki Ora or ECE staff member

Phone number of Wellchild | Tamariki Ora or ECE staff member

Name(s) of sibling(s)

Do you have any other information you would like to add?

Conditions and treatments