Patient Enrolment

Fields marked with * are compulsory

Personal Details

Contact Details

Enter postal address if different from above

Next of Kin

Employer Details

Put NA in employer details if not applicable

I am eligible to enrol because: *

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


A New Zealand Passport


An Overseas Passport
AND Visa

Services Card

Health Information

5. Do you have any family history of:

Which relation of yours?

How old were they at onset of disease?


 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.