Join our Clinic

Join Our Clinic

If you have children under 13 years of age…

Enroll your child if they are less than 13 years old and they get to see us for FREE!

Non-enrolled children will be charged a fee for each consult so it’s better to enroll

If you want to enroll…

Just download and fill in this form, hand it back to us, and bring in an original birth certificate or passport / visa for us to take a copy. Otherwise you can fill out the secure online form below and sign a printed copy of it we will have prepared for you when you come in for your first appointment.

Enrolment is free and allows us to transfer your notes from your previous GP so that we can fully understand your health care needs.

Once you enroll, the Government funds a part of the cost of seeing us thus allowing us to charge you lower fees every time you come in.

There are also certain special programs designed by our PHO for enrolled patients that can be accessed to assist us to care for you better.

If you do not want to enroll…

No worries! Other than having to pay a higher consultation fee, you can rest assured we’ll care for you no differently from our enrolled patients!

We can still access some of your hospital records online with your permission and we do appreciate any medical notes, specialist reports, test results and medication lists you can bring in so we can put them in your notes.

Secure online enrolment form

You can quickly fill out the secure online form below and sign a printed copy of it that we will have prepared for you when you come in for your first appointment. For your first visit please bring in an original birth certificate or passport/visa for us to take a copy of.


ENROLMENT FORM

Fields with * are compulsory.

Anyone over age of 16 years must complete their
own enrolment form.

National Hauora Coalition enrolment form.


 

 

 

Legal Name, Birth details and occupation

 
 

 
 

 
 


 


 

 


 

 
 

 
 

Residential and postal address

 
 

 
 

Your telephone and email contact and emergency contact person details


 

 

 

 

 
 

Transfer of Records


 
 

Community Services & High User Health cards


 

 


 

 

 
 

Ethnicity details*

Which ethnic group(s) do you belong to?

Check the box which you belong to.

 

 

 
 

Smoking quiz


 

If you are aged 15 and over please tick the box that applies to you.

 

 

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?

 

 
 

My declaration of entitlement and eligibility*


 

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.

 

 

 

A. I am a New Zealand citizen

(If yes tick box and proceed to I confirm that, if requested, I can provide proof of my eligibility below)
 

 

(B–J) If you are NOT a New Zealand citizen please tick which eligibility criteria applies to you below:


 

 

 

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 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.

 

Signatory details


 

 

Authority details

(where signatory is not the enrolling person.)