Before proceeding with this form, please note:


∙ Online enrollment will be reviewed by our administration staff, and the registration process will take approximately 1-3 working days to complete

∙ Completion of this online enrollment form is subject to review. If it does not meet the requirements, we will contact you for further information

∙ Patient is required to present to the clinic to sign the enrollment and transfer notes request form. Enrollment is only confirmed once patient has sign the form at one of our reception desks

∙ Medical notes transfer from previous clinic will take an average of 7 working days

∙ A double appointment (30 mins) is required for the first visit


Apply Online Now



Please complete this form to enroll with Tui Medical. Please make sure you fill in all required (*) fields
*To verify your identity, we require you to submit a copy of government-issued photo ID and proof of eligibility for public health funding. We may request additional documents and information where necessary depending on individual circumstances.

Acceptable types of photo ID:
∙ New Zealand Passport
∙ New Zealand Driver's License

Acceptable types of proof of eligibility:
∙ Birth Certificate
∙ New Zealand Visa

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
To download a Blank Enrollment Form for printing, click here

 

Personal Details

Title *
 
Given Name *
 
Middle Name(s)
 
Family Name *
 
Other Name
 
Other Given Name(s)
 
Other Family Name
e.g. maiden name
 
Birth Date *
 
Place of Birth *
 
Country of Birth *
 
Occupation *
 
Gender *
 
Other Gender
 
Ethnicity Details *
Which ethnic group(s) do you belong to? Tick the space or spaces which apply to you. You may select up to 3.
 
Other Ethnicity
 
If Maori - Iwi details
 

Usual Residential Address

House (or RAPID) Number and Street Name *
 
Suburb *
 
Town / City and Postcode *
 
 

Postal Address

(if different from above)

House Number and Street Name or PO Box Number
 
Suburb
 
Town / City and Postcode
 
 

Contact Details

Primary Phone *
 
Secondary Phone
 
Your Email Address *
 
I agree to receiving Txt Messages
 
 

Emergency Contact / NOK

Given Name *
 
Family Name *
 
Relationship *
 
Mobile (or other) Phone *
 
 

ADDITIONAL INFORMATION

Community Services Card
 
Expiry Date
 
Card Number
 
High User Health Card
 
Expiry Date
 
Card Number
 
Smoking Status *
 
Smoking Brief Advice
Did you know smoking is bad for your health? If you are a current smoker would you like brief advice to help you on the right track to quit smoking?
 
 

My Declaration of Entitlement and Eligibility

YES, I wish to enrol with Tui Medical and use this practice as my regular and on-going provider of general practice / health care services. *
 
My preferred medical centre is *
 
I am entitled to enrol because I am residing permanently in New Zealand. *
The definition of residing permanently in NZ is that you intend to be resident in New Zealand for at least 183 days in the next 12 months
 
I am eligible to enrol because:
 
If you are not a New Zealand citizen, please tick which entitlement criteria applies to you (b–j) below:
 
I confirm that I will provide proof of my eligibility. *
 
ID TYPE *
 
ID / Eligibility Document 1 *
 
ID / Eligibility Document 2 *
 
 

My Agreement to the Enrolment Process

NB. Parent or Caregiver to sign if you are under 16 years

I understand that by enrolling with Tui Medical I will be included in the enrolled population of Hauraki PHO, and my name, address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers.

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 PHO provides along with the PHO’s name and contact details.

I have read and I agree with the Use of Health Information Fact Sheet. 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 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.

In order to receive the best care possible, I agree to Tui Medical obtaining my medical records from my previous doctor. I also understand that I will be removed from their practice register.

Name of previous medical centre *
 
City of previous medical centre *
 
Signature
 
Date *
 
Authority *
 
Authority Full Name
 
Relationship
 
Contact Phone
 
Basis of authority
(e.g. parent of a child under 16 years of age)