Enrol (Redhills Health Centre) | Medseek Health Centre

Enrollment for Redhills Health Centre

ENROLMENT FORM

NAME

Title

Given Name

Other Given Name(s)

Family Name

BIRTH DETAILS

Birth Date

Place of Birth

Country of Birth

Gender Gender

OCCUPATION

Company Name

Occupation

Company Address

Work Phone

USUAL RESIDENTIAL ADDRESS

House Number and Street Name

Suburb/Rural Location

Town / City and Postcode

POSTAL ADDRESS

(if different from above)

House Number and Street Name or PO Box Number

Suburb/Rural Location

Town / City and Postcode

CONTACT DETAILS

Mobile Number

Home Phone

Email Address

Do you consent to the practice sending TEXT messages for the purpose of recalls, surveys & updating your details?

Yes

Do you consent to the practice sending EMAILS for the purpose of recalls, surveys & updating your details?

Yes

EMERGENCY CONTACT DETAILS

Name

Relationship

Mobile (or other) Phone

TRANSFER OF RECORDS

I agree to [Practice Name] obtaining my records from my previous doctor, which will mean I will be removed from their practice register.

Transfer of Records

Yes, please request transfer

Not applicable

Previous Doctor

Practice Name

Address

Date

Signature

Clear

ETHNICITY DETAILS

Which ethnic group(s) do you belong to?
Tick the space or spaces which apply to you

Ethnicity Ethnicity

Iwi:

Hapu:

Community Services Card Number

Expiry Date

High User Health Card Number

Expiry Date

Smoking Status (If over 15)

If you are a current smoker or have recently quit, we would like to help you stop to improve your health. Would you like help to stop/stay an ex-smoker?

Would you like to support to quit?

Yes

MY DECLARATION OF ENTITLEMENT AND ELIGIBILITY

I am entitled to enrol because I am residing permanently in New Zealand.

The definition of residing permanently in NZ is that you intend to be resident in New Zealand for at least 183 days in the next 12 months

I am eligible to enrol because:

I am a New Zealand citizen (If yes, tick box and proceed to I confirm that I can provide proof of my eligibility below)

If you are not a New Zealand citizen please tick which eligibility criteria applies to you (b–j) below:

I hold a resident visa or a permanent resident visa (or a residence permit 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 years

I 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)

I am an interim visa holder who was eligible immediately before my interim visa started

I 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 trafficking

I am under 18 years and in the care and control of a parent/legal guardian/adopting parent who meets one criterion in clauses a–f above OR in the control of the Chief Executive of the Ministry of Social Development

I am a NZ Aid Programme student studying in NZ and receiving Official Development Assistance funding (or their partner or child under 18 years old)

I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme

I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund

I confirm that I can provide proof of my eligibility

Evidence sighted (Office use only)

My work/student/visitor/other visa is valid for a period of

Year(s)

Expiry Date

PROOF OF IDENTITY

NZ Passport
NZ Birth Certificate AND Photo ID (e.g. NZ Driver License*)
Citizenship Certificate AND Photo ID
An Australian passport AND proof that you intend to stay in NZ for at least 2 years (i.e. house rental agreement, job contract, etc)
Overseas Passport AND current work visa or other eligible visas as per MOH guidelines.
Questions or queries? Contact reception via the phone. ( phone number )
MOH Guideline

Valid Form of Identification (File Upload)

Maximum file size: 3MB

Passport copy, Photo ID.

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 / health care services.

I understand that by enrolling with the [Practice Name] I will be included in the enrolled population of National Hauora Coalition PHO, 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 Statement. 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 understand that the Practice participates in a national survey about people’s health care 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.I agree to inform the practice of any changes in my contact details and entitlement and/or eligibility to be enrolled.

Signatory Details

Signature

Clear

Date

Self-Signing

Authority

Authority Details

(where signatory is not the enrolling person)

Full Name

Relationship

Contact Phone

Basis of authority (e.g. parent of a child under 16 years of age)

If you are human, leave this field blank.