Enrolment Form

Before you submit your form please make sure you have digital files available to attach for your ID - ideally these files should be less than 2MB in size.
They do not have to be high resolution but please ensure the details are clearly visible.
If you hold an overseas passport please upload a photo of the ID page AND a photo of your visa page in the fields below.

Please note - There will be a new enrolment fee as your first appointment will be a longer consult, as your new Doctor carries out a full medical check.

Personal Details

Location *

Title *

First name *

Middle name

Last name *

Preferred Name

Gender *

Residence Status *

Ethnicity *

Date of birth *

Place of birth *

Country of birth *

Contact Details

Email *

Address 1 *

Address 2

City *

Postcode *

Mobile/Phone *

Next of Kin

First name *

Last name *

Mobile/Phone

Relationship *

Employer Details

Put NA in employer details if not applicable

Documents *

A New Zealand Birth Certificate

AND

A New Zealand Driving Licence

OR

A New Zealand Passport

OR

An Overseas Passport

AND

Work Visa

Other Visa

Services Card

Community Services Card Number

CSC Expiry Date

High User Health Card Number

HUHC Expiry Date

Health Information

1. Are you allergic to anything, especially any drugs/medications?

2. Do you drink alcohol? *

How many drinks per average week?

3. Please select your current smoking status *

How many per day do you/did you smoke?

Would you like help with quitting?

What year did you start smoking?

What year did you stop smoking?

Is there any other information that you would like us to know?

4. Please list any major illnesses/operations/diagnoses you have had

5. Do you have any family history of:

Do you have any family history of Diabetes

Which relation of yours?

How old were they at onset of disease?

Heart Disease

Which relation of yours?

How old were they at onset of disease?

Stroke

Which relation of yours?

How old were they at onset of disease?

Bowel Cancer

Which relation of yours?

How old were they at onset of disease?

6. Females only : What year did you have your most recent cervical smear?

Where did you have your last cervical smear (city/country)?

Was your recent cervical smear result (normal/abnormal/not sure)? please type

Have you ever had an abnormal cervical smear?

If yes, what year?

Consent

I consent to receiving health check reminders (e.g. immunisation and smear reminders), notifications and appointment reminders by Text messaging (SMS).

I consent to medical centre sending me newsletter, surveys and information about services.

Transfer of Medical 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.

Current doctor and/or Practice name, and address (if known)

Do you consent to transfering your medical records to us? *

Authority

Are you enrolling on behalf of the named applicant and giving authority to transfer records? If so please provide the following:

Your Name *

Your Relationship to Applicant *

Your Mobile/Phone *

Please describe the basis or reason for acting as authority eg Parent of applicant under 16 *

Agreement to the enrolment process

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

Terms & Conditions

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

I understand that by enrolling with your Medical Centre I will be included in the enrolled population of the regional PHO 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 visit another health care provider where I am not enrolled I may be charged a higher fee.

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

I have downloaded, read and I agree with the following Use of Health Information Statement. The information I have provided on the Enrolment Form will be used to determine eligibility to receive publicly-funded services. Information may be shared 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.

I agree to the Terms and Conditions of Trade of the Practice and undertake to pay any fees applicable for Practice Services & all costs incurred in collection of any debt for myself & my dependents.

Please sign your agreement in the box below *

Enrolment Form

Personal Details

Contact Details

Next of Kin

Employer Details

I am eligible to enrol because:

Documents *

AND

OR

OR

AND

Services Card

Health Information

5. Do you have any family history of:

Consent

Transfer of Medical Records

Authority

Agreement to the enrolment process

Terms & Conditions