Northpoint Medical Centre in Albany

Register as a casual patient or visitor

This patient form is required by all casual patients or visitors who are not enrolled as patients with our clinic. We require completion of this form before your doctor’s appointment.

* Required Fields

First Name *

Last Name *

Mobile Phone *

Email Address *

Date of Birth *

Gender * FemaleMaleGender Diverse

Emergency Contact (Next of Kin) *

Relationship (Next of Kin) *

Phone Number (Next of Kin) *

Street Address *

Suburb *

City *

Postcode *

Is the patient 16 and over? *YesNo

Authority Name *

Authority Relationship *

Authority Phone *

Authority Basis (Parent/Guardian)*

Current GP

I am currently registered as a patient with another GP in NZ *YesNo

Doctor or Practice Name *

Address / Location *-

Identity Document

Please upload a copy of your valid ID document. e.g. Passport, Drivers License, Birth Cert etc.

Upload another document if required. e.g. Relevant Visa etc.

Agreement and Acknowledgement

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

I acknowledge that I have reviewed the relevant fees displayed/provided to me for services rendered.
I acknowledge to pay for all consultation and service costs at the time of my appointment or request for service.
I acknowledge any payment not completed at the time of my appointment or request for service will incur an additional $15.00 administration fee.
If unpaid after 30 days from the date of service, my account may be placed in the hands of a debt collection agency and all costs associated with this will be my responsibility to pay.

I accept the above enrolment agreement *

Your Signature:

Date *

Casual/Visitor Patient Form

Register as a casual patient or visitor

Current GP

Identity Document

Agreement and Acknowledgement