If you don’t want to complete this form before your first appointment, don’t worry. We supply enrolment forms at all our clinics, and you can complete a form when you come for your first appointment.

Please remember to bring your proof of eligibility when you come to your first appointment.
Eligibility includes NZ Passport OR International Passport with Visa details OR NZ Birth Certificate and Photo ID and proof of address

We will ask you to sign the enrolment form when you come to your appointment.
So don’t forget your proof of identity needs to include your signature, so we can verify your identity.

Clinic *

NHI *

First Name(s) *

Family Name *

Other Names Known By (Maiden/Preferred Name)

Date of Birth *

YYYY

Gender *

Male

Female

Gender Diverse (please state)

Place and Country of birth *

Occupation

Physical Address

Street Number *

Street Name *

Suburb *

City/Town *

Postcode *

Postal Address (if different from physical address)

High User Health Card *

Yes

Community Services Card *

Yes

Contact Details

Day Phone

(###)

###

####

Night Phone

(###)

###

####

Mobile Phone *

(###)

###

####

Accept texts

Yes

Email Address *

Accept emails

Yes

Emergency contact

Name of person to contact

Relationship

Phone no

(###)

###

####

Which ethnic group do you belong to? *

Tick the space or spaces which apply to you

New Zealand European

Māori

Samoan

Cook Islands Maori

Tongan

Niuean

Tokelauan

Chinese

Other such as DUTCH, JAPANESE, TOKELAUAN, FIJIAN

Smoking Status

Current

Ex-Smoker

Never Smoked

Eligibility (see terms) *

I confirm that, if requested, I can provide proof of my eligibility. I agree to inform the practice of any changes in my eligibility.

Eligible under criteria (enter applicable letter from corresponding terms)

Not Eligible (Tick if not eligible under any criteria in terms)

Transfer of Records

Yes

Not Applicable

Interpreter Required

Yes

Thank you!

Enrolment in the Practice / Primary Health Organisation (PHO)

Please read this sheet and identify on your enrolment form which criteria provides your eligibility to funded health services

I am eligible to enrol because I live in New Zealand⁹ and meet one of the following criteria:

A. I am a New Zealand citizen OR

B. I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010) OR

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 OR

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) OR

E. I am an interim visa holder¹⁰ who was eligible immediately before my interim visa started OR

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 OR

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

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) OR

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

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.

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 ongoing provider of general practice / GP / First Level primary healthcare services.

I understand that by enrolling with this practice I will be enrolled with the Primary Health Organisation (PHO) this practice belongs to, and my name address and other identification details will be included on both the Practice, PHO and National Enrolment Service Registers.

I understand that if I visit another 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, and their contact details.

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 eligibility.

Health Information Privacy

I agree to the practice sharing my health information with other health providers involved in my healthcare. 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 also agree to my information being used for practice quality/audit activities and to being included in the practice screening, recall and health programmes.

I have been informed of the Health Information Privacy statement posters.

The definition residing is NZ is that you intend to be resident in New Zealand for at least 183 days in the next 12 months
If a person has an interim visa this means they are waiting for Immigration to finish processing an application as Immigration issues interim visas if the old visa has run out but the new visa is still being processed. To determine the eligibility of an interim visa holder you should look at what their eligibility status was immediately prior to being issued the interim visa. For example, the person had a two year work permit and has been issued with an interim visa while waiting for their application for another two year work permit to be processed. Immigration usually issues Interim visas in a letter form.
An authority is the legal right to sign for another person if for some reason they are unable to consent on their own behalf.