New Patient Enrolment Form

Please allow 1 week for the Enrolment Process. We will request your notes from your previous practice, appointments can be made once these have been received. Before you submit your form please make sure you have digital files to attach for your ID (less than 2MB in size).

Personal Details

Contact Details

Do you want your own account OR joint account with an existing patient?

If joint account please provide details of existing patient.

Next of Kin

In Case of Emergency

I am eligible to enrol because:

Documents *

A New Zealand Passport


A New Zealand Birth Certificate


A New Zealand Driving Licence


An Overseas Passport


A work visa for 2 consecutive years
(if less than 1 year, previous visas also required)
Other visa attachment
(if required)

Services Card

Health Information

Do you have any family history of:

Medical History

Screening History

Immunisation History



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.


Are you enroling on behalf of the named applicant and giving authority to transfer records? If so please provide the following:

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 enroling with Katikati Medical Centre I will be included in the enroled population of the regional 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 enroled I may be charged a higher fee.

I have been given information or informed 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 Health Information Privacy Statement. The information I have provided on the Enrolment Form will be used to determine eligibility to receive publicly-funded services. Information may be shared with other government agencies, but only when permitted under the Privacy Act.

I have read and I agree with the Patient’s Code of Responsibilities.

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 enroled.

I agree to the Terms and Conditions of Trade of Katikati Medical Clinic and undertake to pay any fees applicable for Practice Services & all costs incurred in collection of any debt for myself & my dependents.