Fields with * are compulsory.
Anyone over age of 16 years must complete their own enrolment form.
National Hauora Coalition enrolment form.
  Practice Specified Field (office use only)   NHI (office use only)  
LEGAL NAME Your Title* (Mr, Mrs, Miss, Ms, Dr)
Given Name*
Other Given Name*
Family Name*
   
Other Name(s)
Preferred name(s)
BIRTH DETAILS - Date of Birth - DD-MM-YYY*
Place of Birth*
Country of Birth*
SEX AT BIRTH*  
MaleFemale   GENDER you would like to be identified as  
MaleFemaleGender Diverse (please state)   Preferred Gender Identity
OCCUPATION
PHOTO ID SUPPLIED - Please state:
USUAL RESIDENTIAL ADDRESS*
House (or RAPID) Number and Street*
Suburb / Rural Location*
Town / City*
Postcode*
POSTAL ADDRESS (if different from above)
House Number and Street Name or PO Box
Suburb / Rural Location
Town / City
Postcode
CONTACT DETAILS - phone and email
Home Phone
Mobile Phone
Consent to text   I consent to textI DO NOT consent to text  
Email Address
  Do you consent to signing up to patient portal?   Yes, I consent to signing up for patient portalNo, I DO NOT consent to signing up for patient portal
EMERGENCY CONTACT / NOK DETAILS phone and email
Name
Relationship
Mobile or other phone
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. Yes, please request transfer of my recordsNo transferNot applicable
Previous Doctor and/or Practice Name
Previous Doctor and/or Practice Address / Location
COMMUNITY SERVICES CARD   YesNo   Card Expiry Day / Month / Year
Card Number
HIGH USER HEALTH CARD   YesNo   Card Expiry Day / Month / Year
ETHNICITY DETAILS
Which ethnic group(s) do you belong to?
Check the box which you belong to.
  11 New Zealand European21 Maori31 Samoan32 Cook Island Maori33 Tongan34 Niuean42 Chinese43 IndianOther (such as Dutch, Japanese, Tokelauan…)   If you selected Maori please state your Iwi If you selected "Other" please state your ethnicity
SMOKING IS AN IMPORTANT FACTOR INFLUENCING HEALTH  
If you are aged 15 and over please tick the box that applies to you.
  Currently smokeRecently quitEx-smoker (over 1 year)Never smoked  
Smoking is hugely negative on your good health. In most cases, you will experience the benefit of quitting immediately
 
If you currently smoke, would you like some help to quit?
YesNo
I am entitled to enrol because I am residing permanently in New Zealand.  
The definition of residing permanently in New Zealand is that you intend to be resident in New Zealand for at least 183 days in the next 15 months.
  I am residing in New Zealand permanently   I am eligible to enrol because:  
(If yes tick box and proceed to I confirm that, if requested, I can provide proof of my eligibility below)   A. I am a New Zealand citizen  
B. I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010).C. 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.D. 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).E. I am an interim visa holder who was eligible immediately before my interim visa started.F. 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.G. 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.H. 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. I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme.J. 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, if requested, I can provide proof of my eligibility.   Evidence sighted (Office use only)  
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 Doctors on Luckens I will be included in the enrolled population of National Hauora Coalition, and my name address and other identification details will be included on the Practice, PHO National Enrolment Service Registers.
I understand any threating and aggressive behaviour towards other patients and staff will not be tolerated and in such event I will be asked to leave the surgery premises.
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.
Signature*
Date (Day-Month-Year)*   Self signingAuthority  
(where signatory is not the enrolling person.)
Full name
Authority contact phone
Basis of authority (e.g. parent of a child under 16 years of age.)  
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