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. *
Click here to view terms of enrollment.
 
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. *
 
Date
 
Authority *
 
Electronic Signature Validation *
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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
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