Enrol with us for lower cost healthcare

Personal information

First Name *

Middle Name
(Optional)

Last Name *

Gender *

Male Female Gender Diverse

Mobile Phone *

Date of Birth *

Day

Month

Year

Email Address *

Country of Birth *

Place of Birth *

Other Ethnicities
(Optional)

Street Address *

Suburb *

City *

Postcode *

Is the patient 16 or over? *

Yes No

I give permission for my most recent GP to transfer my patient notes *

Yes No Not Applicable

I agree to receive Email / SMS comms and participate in surveys *

Yes No

Emergency Contact Name *

Emergency Contact Phone Number *

Community Service Card *

Yes No

High User Card *

Yes No

Are You Currently a: *

Non-Smoker Smoker Vaper Ex-Smoker

Enrolment Agreement

My agreement to the enrolment process (NB Parent or caregiver to sign if you are under 16 years). I choose to enrol with this practice as my regular and ongoing provider of general practice / GP / First Level primary health care services.

I understand that by enrolling with this practice I will be enrolled with the Primary Health Organisation (PHO) this practice belongs to, and my name address and other identification details will be included on both the Practice and the PHO Enrolment Register.
I understand that I can visit any clinic in the group as a walk-in patient, and I will only pay the enrolled patient fee of the clinic I am visiting.
I have been given information about the benefits and implications of enrolment with the PHO, and their contact details. I have read and understood the requirements of enrolling with one PHO and choose Tamaki Health Group’s PHO to be my PHO.
I have read and I agree with the Health Information Privacy Statement.
I agree to inform the practice of any changes in my eligibility.
I authorise Tamaki Health Group to pass on parts of my health information to the Ministry Of Health.
I understand that relevant health information may be forwarded to other health professionals involved in my care.
I understand that my health information is accessible by all members of the primary care team and can be accessed at any Tamaki Health Group practice so that continuity of care is facilitated through a shared health record.
I understand that all members of the primary health care team have signed employment contracts containing confidentiality clauses or have signed confidentiality agreements and have completed privacy training so that my personal health information is kept confidential.
I understand that certain information in my daily clinical records can be made confidential to one GP only if required.
I also understand that it is my right under the Health Information Privacy Code 1994 to ask to see my personal or Health Information held by the doctor. I can ask for it to be corrected if it is wrong.
I understand that if I choose to see another doctor I will register at that practice as a Casual Patient, and if I see a GP outside of Tamaki Health Group practices frequently, I may be dis-enrolled from the Tamaki Health Group practices.

I accept the above enrolment agreement

Your Signature:

Proof of Eligibility - Your passport plus the relevant Visa if you are not a NZ Citizen

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