Registration

Introduction

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.

Instructions

Fill in the first column for the primary account holder. Once this is done, you can add or subsequently remove family members by clicking the ADD or DELETE buttons respectively.

A right arrow sign allows you to copy details from the main account holder to family members.

The red cross mark will change to a green tick if all items in that row are valid. Items without this mark are optional.

A green plus mark can be clicked for a new dialog screen to add special items.

For the next-of-kin section, the primary account holder is the default entry for all family members. You can also copy details from one family member to be the main account holder's next-of-kin.

For eligibility documents, you need to process this for each family member individually. On a computer, you can upload one or more documents from your file system. If you are on a mobile device, you have the option of using your device camera to take a photo instead.

The main account holder should sign on the area at the bottom. If this is not done, a text signature based on your name will be used instead.

Submission

Enrol (Transfer)

Registered Provider

Provider

Mandatory Items

Previous GP

Previous GP Practice

Family Name

Given Names

Date of Birth

Place of Birth

Country of Birth

Gender

Ethnicity

Residential Address

Smoking Status

NZ Resident

Residency Status

Optional Items

One of the telephone numbers needs to be filled.

If you plan to use the clinic website services, this email should be used to register on the website.

Preferred Name

Home Phone

Work Phone

Mobile Phone

Postal Address

Next of Kin

Family Name

Given Names

Phone

Type

Relationship

Eligibility Document

Either take a photo with your device or attach a picture / document from your computer.

This is usually a NZ passport / birth certificate or a foreign passport together with a resident / work visa. For children 17 years and younger, a birth certificate can also be used.

If you do not have the eligibility document(s) now, enrolment can still continue but you will need to provide this later.

CSC and HUHC card holders should also include their cards for discounted consults.

Load

Camera

Please sign on your device screen or using a mouse.

If you are enrolling, this authorises us to request for a transfer of your medical records from your previous GP.