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Patient Enrolment Form

Enrol as a patient

The application form should take less than five minutes and there is no cost to enrol. All you need is your passport plus the relevant visa if you are not a New Zealand citizen.

We have simplified the enrolment process to make it hassle-free for you. We require patients to complete the registration/patient form before their first appointment can be scheduled.

Please be advised, the enrolment process takes 10 to 15 working days from the time we receive full paper work.

    * Required Fields

    Personal Details

    FemaleMaleGender Diverse

     

    Address Details

     

    YesNo

     

    DO YOU HAVE ANY, OR HAVE HAD ANY OF THE FOLLOWING MEDICAL PROBLEMS?
    OR IS THERE A FAMILY HISTORY OF THE FOLLOWING:

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

    SelfFamily

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    SelfFamily

    SelfFamily

    SelfFamily

    Other Details

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNoDon’t know

     

    YesNo

    YesNo

    YesNo

     

    Transfer of Records

    To get the best care possible, I agree to the Practice of obtaining my records from my previous Doctors. I also understand that I will be removed from their practice register.

    YesNoNot Applicable

     

    Patient Surveys

    I understand that the Practice participates in a national survey about people’s health care experience and how their overall 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.

    TICK HERE TO OPT OUT/DECLINE

     

    Patient Portal

    YesNo

     

    Declaration of Entitlement and Eligibility

    * Please read this sheet carefully to identify your criteria which will provide for your eligibility for funded health services

    I am eligible to enrol because:

    I am a New Zealand citizen (inc. Cook Islands, Niue or Tokelau)I hold a resident visa or permanent resident visa (or a residence permanent if issued before December 2010)I am an Australian citizen or Australian permanent resident AND able to show I have been in New Zealand or intend to stay in New Zealand for at least 2 consecutive yearsI have a work visa/permit and can show that I am able to be in New Zealand for at least 2 years (previous permits included)Other

    I am an interim visa holder who was eligible immediately before my interim visa startedI am a refugee or protected person OR in the process of applying for, or appealing refugee or protection status, OR a victim or suspected victim of people traffickingI am under 18 and in the care and control of a parent/legal guardian/adopting parent who meets one criterion listed aboveI am 18 or 19 years old and can demonstrate that, on the 15th of April 2015, I was the dependant of an eligible work permit holderI am a NZ Aid Programme student studying in NZ and receiving official Development Assistance funding (or their parent or child under 18 years old)I am participating in the Ministry of Education Foreign Language Teaching Administration schemeI am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand universityI am under the Commonwealth Scholarship and Fellowship fund-

     

    I confirm that I can provide proof of my eligibility * Mandatory

    Proof of Eligibility

    Please upload a copy of your passport, plus the relevant Visa if you are not a NZ Citizen

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

    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 / First level health care services.

    • I understand that by enrolling with this practice I will be included in the enrolled population of Primary Health Organisation (PHO – Alliance Health Plus), 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.

    • 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 agree to inform the practice of any changes in my contact details and entitlement and/or eligibility to be enrolled.

    Terms of trade

    • 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.

    Your Signature:

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