Personal Details

Title *
Given Name *
Middle Name(s)
Family Name *
Birth Date *
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 *
Smoking Status *

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. *
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My preferred Tui Medical Centre
I reside permanently in New Zealand. *
I intend to legally reside in New Zealand for at least 183 days in the next 12 months
I agree to provide proof of my eligibility. *
Name 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