Enrolment -

Surname:
Maiden Name:
First/Middle Names:
Preferred Name:
Title:
Date of birth:

Residential address (+ Postal code):
Postal Address (if different from above):
Next of kin + relationship:
Contact Number:-
CSC Number:
Expiry Date:
Phone Numbers:-
Day:
Night:
Cellphone:
Email:

Occupation:

Ethnicity:

Txt Messaging:

I consent to receive generic'Txt messages are Appts, Recalls & Results

Yes

Permanent Resident of NZ:

Yes

If not

When did you arrive in NZ:

How long will you be living in NZ:

Have you seen a Doctor/Hospital in NZ:

Yes

By enrolling with this medical practice and signing this form I understand that:

I intend to use this medical practice as my main provider of primary health care.
This medical practice is contracted to Nelson Bays Primary Health Organisation (PHO).
This medical practice will receive government funding to subsidise my healthcare, reducing the amount I would otherwise have to pay for some services.
The details on this form will be recorded in the medical practice enrolment register. This register will be submitted to the PHO (or its agent) and Ministry of Health so that the practice can receive appropriate funding. The date and status of my enrolment and the date of my last consultation with the practice will also be submitted for audit and monitoring of the medical practice and PHO. Details of my health status or treatment will not be submitted.
I can only be enrolled with one medical practice at any one time.
I may visit any other medical practice but this will be as a casual patient and may affect the amount I have to pay. The PHO will be informed of this visit, but not my health status or treatment, for funding purposes only.
I may end my enrolment with this medical practice at any time.
I retain the right to obtain access to and request correction of any of my information held by the medical practice.
Details about my health status or treatment will remain confidential within the medical practice unless I give specific and separate consent for this to be communicated elsewhere.
I agree to pay for all consultations promptly, including any fees that may accrue. Accounts will be charged an account fee if not paid within five (5) working days. I understand that unpaid accounts may be referred to a debt collection agency and all costs incurred I the recovery will be my responsibility.

If transferring from another medical practice

I agree that this medical practice can obtain clinical records and copies of any health information about me from the practice I previously attended for the purpose of recording my health status and to assist in my future care and treatment.

Name of previous medical practice
Signed
Date
Relationship if not person named above
Name (print)

It is also helpful if we can obtain information about your current medical status when joining the practice as outlined in the form below:

Have you ever suffered from any of the following conditions?

Please give details.
Asthma:
Diabetes:
High blood pressure:
Epilepsy:
Stroke:
Kidney disease:
Heart disease - Please state:
Other - Please state:
Have you had any operations? - Please state:

Has anyone in your family (Parent/Brother/Sister/G'Parent/Aunt/Uncle-suffered from any of the following conditions?
(Below) Please give details.

Asthma:
Diabetes:
High blood pressure:
Epilepsy:
Stroke:
Kidney disease:
Heart disease - Please state:
Other - Please state:
Have you had any operations? - Please state:

Please list any medication that you are taking:

Are you a smoker?
How many cigarettes a day?
How many years have you been a smoker?
If you are an ex-smoker:
When did you stop smoking?
If you drink alcohol:
How much do you consume a week?
Do you exercise regularly?
What type?
How many times a week?
For how many minutes?
When was your last Tetanus vaccination?
Do you have any allergies - please state:
For women only:
When was your last smear?
Was this your first smear?
Have you had an abnormal smear?
If so, when?
When was your last mammogram?