Enrol as our Patient

Parent/Guardian/Caregiver

Smoking/Vaping

Entitlement

Eligibility

I am eligible to enrol because:

This agreement outlines the enrolment terms and conditions. (If the applicant is under 16 years old, a parent, guardian, or caregiver must sign on their behalf).

I choose to enrol with this practice as my regular and ongoing provider of general practice and primary health care services.

• By enrolling with this practice, I understand that I will be included in the enrolled population of this practice’s Primary Health Organisation (PHO). My name, address, and other identifying details will be included on the registers of the practice, PHO, and National Enrolment Service. Personal information and clinical notes may be shared with other health providers or third-party organisations as part of my healthcare, such as ACC, insurance companies, the Ministry of Health, and WINZ.

• I have been provided with information about the benefits and implications of enrolling with the PHO, along with their contact details. I have read and understood the requirements for enrolling with a PHO and choose this practice’s PHO to be my provider.

• I have read and agreed to the Health Information & Privacy Statement. The information I have provided on the enrolment form will be used to determine my eligibility for publicly funded services. This information may be compared with that of other government agencies, but only as permitted under the Privacy Act.

• I understand that the practice participates in a national survey regarding people's healthcare experiences and the management of their overall care. Participation is voluntary, and all responses will remain anonymous. I can decline to take part in the survey or opt out by informing the practice. The survey results are used to enhance health services.

• I agree to inform the practice of any changes to my contact details and my entitlement and/or eligibility for enrolment.

• I  understand and accept the standard payment terms and conditions

• I acknowledge that if I visit a provider where I am not enrolled, I may incur a higher fee.

• I accept the above enrolment agreement.