X-Ray Certificate For Temporary Entry (Inz 1096) (Page 3 of 4) in pdf

Passport/identification number

Radiologist/radiographer initials

Section B

Details of person having chest X-ray examination

This section must be completed by the person having the chest X-ray examination before attending the examination.

Name as shown in passport

Family/last name

Given/first name(s)

Full home address

Telephone (daytime)

Gender

Male

Female

Date of birth

Country of birth

Country of citizenship

Section C

Declaration of person having chest X-ray examination

This declaration must be signed and dated by the person having the chest X-ray examination, in the presence of the

radiographer or radiologist.

A parent or guardian must sign on behalf of a child under 16 years of age.

Please read carefully before signing.

I declare that the details given by me to the radiologist or radiographer on this X-ray certificate and set out in

section A of this certificate are true and correct in every respect.

I declare I will inform INZ of any relevant fact or any change of circumstances that may affect the decision on my

application for a permit or visa due to my health circumstances.

I authorise INZ to make any enquiries it deems necessary in respect of the information provided on this form and to

share this information with other Government agencies (including health service agencies and overseas agencies) to

the extent necessary to make a decision about my immigration status.

I authorise any New Zealand health service agency to provide information about my state of health to INZ.

I undertake to pay the fees for this X-ray examination and I also agree that I or my child will undergo, at my expense, any

further examinations that may be required by INZ in respect of the immigration application.

I agree that the radiologist or radiographer who completes this certificate may release to INZ, any information acquired

with regard to the health of myself or my child.

I understand that if I make any false statements, or provide any false or misleading information or have changed or

altered this certificate in any way, my application may be declined, or my visa or permit may be revoked, and that I may be

committing an offence and be liable to prosecution and imprisonment.

Signature of person having chest X-ray

Date

(or parent or guardian)

Full name of parent or guardian

Relationship to person having chest X-ray

Signature of radiographer or radiologist

Date

Name of radiographer or radiologist

This form has been approved under section 132(1) of the Immigration Act 1987

X-Ray Certificate for Temporary Entry – 3

X-Ray Certificate For Temporary Entry (Inz 1096) Page 3

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