Title *
Given Name *
Other Given Name(s)
Family Name *
Other Name(s)
Birth Date *
Place & Country of Birth *
City *
Country * Select... New Zealand Australia ------------- Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombi Comoros Congo (Brazzaville) Congo Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor (Timor Timur) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Morocco Mozambique Myanmar Namibia Nauru Nepa Netherlands Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe
Gender *
Occpation *
Company Name
Company Address
Work Phone
Work E-Mail
Usual Residential Address *
House (for RAPID) Number & Street Name *
Address Line 2 *
Town / City *
ZIP / Postal Code *
Postal Address (if different from above)
House Number & Street Name or PO Box Number
Suburb / Rural Delivery
Town / City
ZIP / Postal Code
Mobile Phone
Home Phone
E-Mail Address
First Name *
Last Name *
Relationship *
Mobile (or other) Phone *
In order to get the best care possible, I agree to the Practice obtaining my records from my previous Doctor. I also understand that I will be removed from their practice register.
If selected yes, please place your previous doctor and/or practice name here:
If selected no transfer, or not applicable, please place address/location here:
Which ethnic grooup do you belong to? Tick the space or spaces which apply to you:
Expiry Date
Card Number
Expiry Date
Card Number
Comments
Declaration of entitlement & eligibility 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 I am a New Zealand Citizen. *
If yes, tick the box and proceed and to I confirm that, if requested, I can provide proof of my eligibility below) *
I am not a New Zealand Citizen
Please tick which eligibility criteria applies to you from the following options.
I confirm that, if requested, I can provide proof of my eligibility.
My agreement to the enrolment process NB. Parent or Caregiver to sign if you are under 16 years.
I intend to use this practice as my regular and on-going provider of general practice / GP / health care services.
I understand that by enrolling with this practice I will be included in the enrolled population of the Primary Health Organisation this practice belongs to 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 no 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, and PHO provides along with the PHO's name and contact details. (ProCare Health Ltd. Level 2, 110 Stanley Street, Grafton Ph.09-3777827 www.procare.co.nz)
I have read and I agree with the Use of Health Information Statement. 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 of 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.
Date *
An authority has the legal right to sign for another person if for some reason they are unable to consent on their own behalf.
Authority Details
(Where signatory is not the enrolling person) First Name
Last Name
Relationship
Contact Phone
Basis of Authority (e.g. parent of a child under 16 years of age)
Please also send a copy of your Passport with Visa for Non-New Zealand born, or NZ Passport or birth Certificate for New Zealand Born to reception@botanygp.co.nz
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