Enrollment Form

Name *

Title *

Given Name *

Other Given Name(s)

Family Name *

Other Name(s)

Birth Date *

Place & Country of Birth *

City *

Country *

Gender *

Male

Female

Gender Diverse (please state below)

Employment Details *

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

Contact Details *

Mobile Phone

Home Phone

E-Mail Address

Emergency Contact *

First Name *

Last Name *

Relationship *

Mobile (or other) Phone *

Transfer of 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.

Yes. Please request transfer of my records.

No. Do not transfer.

Not applicable.

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:

Ethnicity Details *

Which ethnic grooup do you belong to? Tick the space or spaces which apply to you:

New Zealand European

Maori

Samoan

Cook Island Maori

Tongan

Niuean

Chinese

Indian

Other. Please state below:

Community Services Card

Yes

No

Expiry Date

Card Number

High User Health Card

Yes

No

Expiry Date

Card Number

Do you Smoke?

Yes

No (ex-smoker)

Never

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. *

Yes

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) *

Yes

If you are not, please move to the section below.

I am not a New Zealand Citizen

Please tick which eligibility criteria applies to you from the following options.

I hold a resident visa or a permanent resident visa (or a residence permit 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 old 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 Common wealth Scholarship and Fellowship Fund.

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.

Signatory Details *

Signature *

Signature (Above) Clear Signature

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.

Self-Signing

Authority

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

Kindly schedule your appointment in advance to guarantee seeing a doctor, as walk-in appointments are hardly available.

Please note that our eastside family doctors will start seeing their patients at our premises in

Botany Medical & Urgent care ( Botany Town Centre)

Covid-19 Approved Vaccine & Testing Facility

Patient Enrollment Form

Declaration of entitlement & eligibility

My agreement to the enrolment process