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Personal Details

Title *

First name *

Middle name

Last name *

Preferred Name

Gender *

Residence Status *

Ethnicity *

Date of birth *

Place of birth *

Country of birth *

Contact Details

Address (Type and select address only from the list)

Mobile Phone *

Email (put NA if you don't have one)

Postcode

Country *

Enter postal address if different from above

Street

Suburb

City

Postcode

Country

Next of Kin

First name *

Last name *

Mobile Phone

Relationship *

Street *

Suburb *

City *

Postcode *

Employer Details

Put NA in employer details if not applicable

Name *

Address (Type and select address only from the list)

Occupation (type and select from the list) *

Work Phone

I am eligible to enrol because: *

I am a New Zealand citizen.

I hold a resident visa or permanent resident visa (or a residence permanent if issued before December 2010)

I am an Australian citizen or Australian permanent resident AND able to show I have been in New Zealand or intend to stay in New Zealand for at least 2 consecutive years

I have a work visa/permit and can show that I am able to be in New Zealand for at least 2 years (previous permits included)

I am an interim visa holder who was eligible immediately before my interim visa started

I am a refugee or protected person OR in the process of applying for, or appealing refugee or protection status, OR a victim or suspected victim of people trafficking

I am under 18 years and in the care and control of a parent/legal guardian/adopting parent who meets one criterion in clauses above or in the control of the Chief Executive of the Ministry of Social Development

I am a NZ Aid Programme student studying in NZ and receiving Official Development Assistance funding (or their partner or child under 18 years old)

I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme

I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund.

Transfer of Medical Records

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.

Current doctor and/or Practice name, and address (if known)

Documents *

A New Zealand Birth Certificate

AND a New Zealand Driver's License

OR

A New Zealand Passport

OR

An Overseas Passport

AND Visa

Services Card

Community Services Card number

Expiry Date

High User Health Card Number

Expiry Date

Health Information

1. Are you allergic to any medication?

2. Do you drink alcohol?

How many drinks* per average week?

3. Please select your current smoking status *

How many per day do you/did you smoke?

Would you like help with quitting?

What year did you start smoking?

What year did you stop smoking?

Is there any other information that you would like us to know?

4. Please list any major illnesses/operations/diagnoses you have had

5. Do you have any family history of:

Which relation of yours?

How old were they at onset of disease?

Diabetes

Heart Disease

Stroke

Bowel Cancer

6. Females only : What year did you have your most recent cervical smear?

Where did you have your last cervical smear (city/country)?

Was your recent cervical smear result (normal/abnormal/not sure)? please type

Have you ever had an abnormal cervical smear?

If yes, what year?

Consent

I consent to receiving health check reminders (e.g. immunisation and smear reminders), notifications and appointment reminders by Text messaging (SMS)

I consent to medical centre sending me newsletter, surveys and information about services

I wish to be texted an activation code for Manage My Health (patient portal) so that I can access my own notes, results, prescriptions etc.

My agreement to the enrolment process

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

Terms & Conditions

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 Victoria Clinic I will be included in the enrolled population of Pinnacle 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 and PHO provides along with the PHO’s name and contact details.

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.

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

Please sign in the box below *

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Patient Enrolment

Fields marked with * are compulsory