ENROLMENT FORM Page 2

Enrolment Form

Practice name:: CityMed Doctors Ltd Phone number: 09 3775525 Address: 8 Albert St, Auckland, 1010 EDI number: victormc Fax number : 09 -379 3793

Title* Surname* First Name(s)* Mr Mrs Ms Miss Dr Preferred name Other names known by (e.g. maiden name)

Date of birth* Gender* Male ☐ Female ☐ day month year Physical address* Place of birth* Street or rapid (rural) no. Name of street Suburb

Suburb City/town Postcode City/town

Country Country

Postal address

Day phone Night phone

Cellphone email Occupation

Which ethnic group do you belong to? Mark the space or spaces which apply to you Do you agree to receive text messages? Yes ☐ No ☐ New Zealand European Emergency contact Maori Name Relationship Phone

Samoan

Cook Islands Maori

Tongan Private health insurer:

Niuean Community Services Card Card number

Chinese Expiry date

Indian High User Health Card Card number Other such as DUTCH, JAPANESE, TOKELAUAN. Expiry date Please state: Do you smoke? Yes ☐ No (ex smoker) ☐ Never ☐ Transfer of records: for continuity of my care, I agree to the practices transferring my records from my previous doctor. I also understand that I will be removed from their practice register.

Yes ☐ No ☐ Doctor’s name Address/location Signature Date

Dependants listed on this form will also be enrolled in the PHO as long as I am legally entitled to sign on their behalf (see below) Authorised representatives can enrol dependants. In the case of a dependant child under 16 years old, the process can be completed by a parent or caregiver who is the legal guardian or who has custody. It is recommended that each child is enrolled on his/her own form.

NHI* First names* Family name* Gende Ethnicity/ Date Country of birth* r* ethnicities* of

ENROLMENT IN THE PRACTICE / PRIMARY HEALTH ORGANISATION (PHO ) I intend to use as my regular and ongoing provider of general practice / GP /

* mandatory to complete

I agree I have read I agreeand I have givenbeen I understand thatif visit another providerI whereI am not enrolledI may be charged higherfee.a my addressname, and other identification detailswillincluded be theon both Practice PHO and the Enrolment Register. Iunderstand thatby enrolling thiswith practice be I will enrolled Primary Health thewith Organisation practice(PHO) this belongs to, and I MYAGREEMENT TO ENROLMENT THE PROCESS Commonwealth ScholarshipandFellowship Fund. ☐ ☐ funding(or partnerchild their underyears or 18 old) ☐ ☐ ☐ status aor OR suspected, victim of peoplevictim trafficking ☐ ☐ ☐ stayinNew Zealand for atleast 2consecutive years ☐ ☐ ☐ I livein ZealandNew I am eligible to enrol First Level healthcareprimary services. * An authority is the legal right to sign for another person if for some reason they are unable to consent on their ownare ifunablebehalf. legaltheytoconsent some * another personreason is on An their to sign authority the for right for tocomplete* Mandatory choose tochoose enrol practicewith this myas regular on going and providerofgeneral practice / First/ GP Level healthcare primary services. (e.g. parent of childparenta16): (e.g. under basisof authority Detail the Address of authorityFull name signed by OR authority** Signature*

h. Iam 1918h. yearsor andold can demonstrate that,the April 152011, on I was the dependant of eligible an workpermit holder Iam under yearsg. 18 andin the care and control parent/legalof a guardian/adopting parentmeets who one criterionclauses in abovea–f f. refugeeI am a or protectedperson ORthe in processapplying of for, or appealingrefugee or protection I am e. interiman who is visa holder eligible immediately before my interimvisastarted Ihaved. work a visa/permit and can show thatIam able to Newbe in Zealand forat least 2years (previous included)permits an c. I am Australiancitizen Australian or permanent resident able ANDto show I have been in ZealandNew or intend to Iholda b. resident visaor a permanentresident a visa (or residencepermit issued if beforeDecember 2010) a a. NewI am Zealandcitizen (including those fromIslands, Niue Cook or Tokelau) k. I am a Commonwealthk. I am Scholarship holder studying in ZealandNew andreceiving funding froma New Zealand university under I am j. participatingin Ministrythe Education of Foreign languageTeaching Assistantship scheme NewI am i. a Zealand Aid Programme student studying in New Zealandandreceiving Official DevelopmentAssistance to informthe practice of any changesin my eligibility. information the about benefits and implicationsenrolment of PHO, thewith contactand their details. because andmeet of followingone the statements:eligibility with Health thewith Information Privacy Statement in accompanyingPHO information. I am residing permanently Newin Zealand ENROLMENT FORM – page 2

Signature Signature of authority Contact numberphone OR OR OR . * * * (please tick) NB NB Parent caregiver or to if yousign are under years 16 OR OR OR Day Date* Relationship Day Date* OR month month OR OR year year OR

PRO_05_13_004_May_ 2013