Patient Enrolment / Registration (Select One)
Thank you for your interest in registering with our healthcare practice.
When you complete this form, you have the option of enrolling with the general practice primary health organisation (PHO) of which this practice is a member or registering as a casual patient without enrolling. Whilst enrolment with a PHO is voluntary, enrolment provides you and your whānau | family with access to subsidised healthcare services including reduced costs for doctors' visits and prescription medications.
You can only be enrolled at one healthcare practice at a time, but you can change your enrolled practice at any time should you wish to move to another healthcare practice.
To enrol, you must meet criteria as detailed on the Te Whatu Ora | Health New Zealand website enrolment page. If you are a New Zealand Citizen, Permanent Resident, or hold a work visa, you will be eligible to enrol. The information collected at enrolment is subject to the Privacy Act 2020 and the Health Information Privacy Code 2020, so the privacy of your information is protected. To enrol, you will need to provide proof of eligibility by uploading documents as evidence of your eligibility to enrol.
If you are not eligible or do not wish to enrol at this practice, you can also use this form to visit the practice as a casual patient. All patients who are not enrolled with the practice are considered to be casual patients.
Mandatory Items:
Registered Provider:
Previous GP:
Family Name:
Given Names:
Date of Birth:
Place of Birth:
Country of Birth:
Gender: Male / Female / Gender Diverse (Select One)
Ethnicity:
Residential Address:
Smoking Status: Non-smoker / Current smoker / Ex-smoker, stopped (Select One)
NZ Resident: Yes / No (Select One)
Optional Items:
Preferred Name:
Email:
Home Phone:
Work Phone:
Mobile Phone:
Postal Address:
Next of Kin:
Family Name:
Given Names:
Phone:
Type: Home / Work / Mobile (Select One)
Email:
Relationship: Husband / Wife / Sister / Brother / Son / Daughter / Mom / Dad / Gran / Grandpa (Select One)
Signature: Date:
