Enrol | Tui Medical

Personal Details

Title *

Given Name *

Middle Name(s)

Family Name *

Birth Date (DD/MM/YYYY) *

Day

Month

Year

Country of Birth *

Gender *

Male

Female

Gender diverse

Ethnicity Details

Residential Address

House Number and Street Name *

Suburb *

Town / City and Postcode

Contact Details

Primary Phone *

Your Email Address *

Emergency Contact / NOK

Given Name *

Family Name *

Relationship *

Mobile (or other) Phone *

My Declaration of Entitlement and Eligibility

YES, I wish to enrol with Tui Medical for General Practice healthcare services. *

Yes

I agree to the terms of enrollment. *
Click here to view terms of enrollment.

Yes

My preferred Tui Medical Centre

I agree to provide proof of my eligibility. *
Click here to view accepted proof of eligibility documents

Yes

ID / Eligibility Document 1 *
TIP: Tap on Choose File,
select Camera or Take a Photo

ID / Eligibility Document 2
TIP: Tap on Choose File,
select Camera or Take a Photo

Name of previous medical centre *

Location of previous medical centre *

I agree to Tui Medical obtaining my medical records from my previous doctor. *
Yes

Date

Authority *
Self
On behalf of

Electronic Signature Validation *
Validate Signature Clear Signature

Authority Full Name (On Behalf Of)

Relationship

Contact Phone

To download a Blank Enrollment Form for printing, click here

For more details on Eligibility, click here
For more details on our Privacy Policy, here
For more details on our Use of Health Information Fact Sheet, click here