• Enrolment Form

  • Date of Birth
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    2 digit day, 2 digit month, 4 digit year
  • Gender

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  • Do you agree to receive emails for communication and updates?
  • Transfer of Records - In order to get the best care possible, I agree to the Practice obtaining my records from my previous Doctor. I also understand that I will be removed from their practice register.
  • Do you agree to receive text messages?
  • Ethnicity Details - Which ethnic group(s) do you belong to? Tick the space or spaces which apply to you

  • Community Services Card
  • CSC Expiry date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Do you smoke?

  • My declaration of entitlement and eligibility

  • I am entitled to enrol because I am residing permanently in New Zealand. (plan to be in New Zealand for at least 183 days in the next 12 months)
  • If you are NOT a New Zealand citizen - please tick which eligibility criteria applies to you (b-j) below:
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    Cancelof
  • Take Photo of your evidence (i.e. Passport, Visa, Birth Certificate, etc)
  • Take Photo of your evidence - if you need another photo

  • My agreement to the enrolment process

    NB. Parent or Caregiver to sign if you are under 16 years

     

    I intend to use this practice as my regular and on-going providder of general practice / GP / health care services

    I understand that by enrolling with this practice, I will be included in the enrolled population with the Primary Health Organisation (PHO) this practice belongs to, and my name address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers.

    I understand that if I vist another health care provider where I am not enrolled I may be charged a higher fee.

    I have been given information about the benefits and implications of enrolment and the services this practice and PHO provides along with thee PHO's name and contact details.

    I have read and I agree with the Use of Information Statement. The information I have provided on the Enrolment Form will be used to determine eligibility to receive publicly-funded services. Informationmay be compared with other government agencies, but only when permitted under the Privacy Act.


    I understand that the Practice participates in a national survey about people’s health care experience and how their overall care is managed. Taking part is
    voluntary and all responses will be anonymous. I can decline the survey or opt out of the survey by informing the Practice. The survey provides important
    information that is used to improve health services.

    I agree to inform the practice of any changes in my contact details and entitlement and/or eligibility to be enrolled.

     

  • Clear
  • Date of signature
     - -
    2 digit day, 2 digit month, 4 digit year
  • Who signed this?

  • An authority has the legal right to sign for another person if for some reason they are unable to consent on their own behalf.

    Authority Details: (where signatory is not the enrolling person)

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  • Should be Empty: