Date Format: DD slash MM slash YYYY
In order to get the best care possible, I agree to the Practice obtaining my records from my previous Doctor. I also understand that I will be removed from their practice register.
Which ethnic group(s) do you belong to? Tick the space or spaces which apply to you.
Declaration of entitlement and eligibility
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.
If yes, tick the box and proceed and to I confirm that, if requested, I can provide proof of my eligibility below)
Please tick which eligibility criteria applies to you from the following options.
Evidence sighted (Office use only)
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 this practice I will be included in the enrolled population of the Primary Health Organisation this practice belongs to 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 no 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. (ProCare Health Ltd. Level 2, 110 Stanley Street, Grafton Ph.09-3777827 www.procare.co.nz)
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.
(Where signatory is not the enrolling person)