Account details change request form

This is a custom lang string for instructions to display on the account details change request form.

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There are required fields in this form marked .

Previous email address

Where did you previously work or study?
Provide any email addresses you have used.

New Details

Full name

Health NZ Employee Number (if applicable)

New work email address

Confirm your new work email address

APC number (if applicable to your profession)

HPI/CPN number (if applicable to your profession)

Choose your position

Employer name

Select the location you most often work or study

Job Title

Manager Details (if changed)

Manager's full name

Manager's email address