New Enrolment Form

Fields with * are compulsory

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

NHI

(Office use only)

Name

Title
Given Name
Other Given Name
Family Name
Other Name(s) (eg. maiden name)
Occupation
Employer

Birth Details

DD slash MM slash YYYY
Place of Birth(Required)
Country of birth(Required)

Gender (*)

Usual Residential Address

House Number and Street Name (*)
Suburb/Rural Location (*)
Town / City and Postcode

Postal Address (if different from above)

House Number and Street Name or PO Box Number
Suburb/Rural Delivery
Town / City and Postcode

Contact Details

Mobile Phone(Required)
Home Phone
Email Address(Required)

Emergency Contact

Name
Relationship
Mobile (or other) Phone

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.

Previous Doctor and/or Practice Name
Address / Location

Ethnicity Details Which ethnic group(s) do you belong to? Tick the space or spaces which apply to you

Community Services Card
Day / Month / Year of Expiry
Card Number
High User Health Card
Day / Month / Year of Expiry
Card Number
Do you Smoke?
Disabilities
Comments

My declaration of entitlement and eligibility

I am entitled to enrol because I am residing permanently in New Zealand.

I am eligible to enrol because:

If you are not a New Zealand citizen please tick which eligibility criteria applies to you (b–j) below:

I confirm that, if requested, I can provide proof of my eligibility

Evidence sighted (Office use only)

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 the Primary Health Organisation 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 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.

Signatory Details

Signature
DD slash MM slash YYYY

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)

Full Name
Relationship
Contact Phone