Personal Details

Title *
Given Name *
Middle Name(s)
Family Name *
Birth Date (DD/MM/YYYY) *
Country of Birth *
Gender *
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. *
I agree to the terms of enrollment. *
Click here to view terms of enrollment.
My preferred Tui Medical Centre
I agree to provide proof of my eligibility. *
Click here to view accepted proof of eligibility documents
ID / Eligibility Document 1 *
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ID / Eligibility Document 2
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Name of previous medical centre *
Location of previous medical centre *
I agree to Tui Medical obtaining my medical records from my previous doctor. *
Authority *
Electronic Signature Validation *
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Authority Full Name (On Behalf Of)
Contact Phone