Anyone over the age of 16 years must complete their own enrolment form

Patient Enrolment Form

Legal Name

Other Name(s)

Gender *

Usual Residential Address *
Usual Residential Address
House (or RAPID) Number and Street Name
Suburb
Town/City
Region
Postcode
Postal Address (if different from above)
Postal Address (if different from above)
House (or RAPID) Number and Street Name
Suburb
Town/City
Region
Postcode

Contact Details

Emergency Contact

Community Services Card

Do you have one? *

High User Health Card

Do you have one? *

Smoking Status

Are you a smoker? *
Would you like any support to quit?

Ethnicity Details

Which ethnic group(s) do you belong to? Tick the boxes which apply to you *

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. *

My declaration of entitlement and eligibility

The definition of residing permanently in NZ is that you intend to be resident in New Zealand for at least 183 days in the next 12 months
I am eligible to enrol because:
(If yes, tick box and proceed to I confirm that, if requested, I can provide proof of my eligibility below)
If you are not a New Zealand citizen please tick which eligibility criteria applies to you below:
*

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 provider of general practice / GP / health care services.

I understand that by enrolling with this Practice I will be included in the enrolled population of WellSouth PHO (Primary Health
Organisation) 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 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 read and I agree with the 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 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.

Authority Details

An authority has the legal right to sign for another person if for some reason they are unable to consent on their own behalf (where signatory is not the enrolling person)