Enrolment

PERSONAL DETAILS

NHI Number (if known):

Title:

Given Name:

Middle Name(s):

Family Name:

Preferred Names:

Assigned Sex (at Birth):

Gender:

Date of Birth:

Country of Birth:

Place of Birth:

Preferred Language:

Which ethnic group(s) do you belong to? Select the ethnicities that apply to you.

Primary Ethnicity:

Secondary Ethnicity:

Tertiary Ethnicity:

Iwi 1:

Iwi 2:

Iwi 3:

RESIDENTIAL ADDRESS

Street Number and Name:

Suburb:

Town / City:

Postcode:

My residential and postal addresses are the same

POSTAL ADDRESS

Street Number and Name:

Suburb:

Town / City:

Postcode:

CONTACT DETAILS

Mobile Phone:

Work Phone:

Home Phone:

Email Address:

Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Contact Relationship:

Emergency Contact Phone:

Smoking Status:

If you currently smoke, would you like some help to quit?

Yes

Community Service Card Number:

Community Service Card Expiry:

High Use Health Card Number:

High Use Health Card Expiry:

Occupation:

Employer / School:

Employer Address:

Employer Suburb:

Employer City:

Employer Postcode:

Employer Phone:

Patient remarks (e.g. Dr X is my preferred GP):

Do you agree to this practice obtaining your medical records from your previous doctor?

Yes

Name of Previous Doctor/Practice:

Location of Previous Doctor/Practice:

Please sign below (clear signature)

Authority:

Where signatory is not the enrolling person: An authority has the legal right to sign for another person if for some reason they are unable to consent on their own behalf (eg: parent of a child under 16 years of age).

New Zealand Citizens:

New Zealand Passport (No further documentation required); OR
New Zealand Driver's Licence, AND one of the following:
- Birth Certificate
- Community Services Card

New Zealand Residents and Other Eligible Persons:

Passport, AND one of the following:
- NZ Visa (at least 2 years)
- Residence Permit

PERSONAL DETAILS

RESIDENTIAL ADDRESS

POSTAL ADDRESS

CONTACT DETAILS

MY DECLARATION OF ENTITLEMENT AND ELIGIBILITY