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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 (must be more than 2 years/resident visa)


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