Office visit registration form

We want to keep our people and clients as safe as possible during the COVID-19 Pandemic. If you’re visiting one of our offices, you’ll need to register your visit using this form before you enter our premises.

Name*
First Last
Mobile phone number*
Email address*
Which WRMK office are you visiting today?*
- Whangarei
- Dargaville
- Kerikeri
- Warkworth
Who are you visiting today?*
Please name the person you have an appointment with or the reason for your visit e.g. making a repair or delivery.
Health screening questions
Have you recently returned from overseas or been in contact with someone who has recently returned from overseas?*
- Yes
- No
Have you been in close contact with anyone who is currently required to self-isolate?*
- Yes
- No
Have you recently been exposed to, or possibly exposed to anyone who is confirmed as having the COVID-19 virus?*
- Yes
- No
Are you currently experiencing any flu like symptoms?*
- Yes
- No
Declaration*
By checking the box below you indicate you confirm you have completed this form honestly and to the best of your knowledge.
- I declare the information provided here is correct to the best of my knowledge
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