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

Title *

First name *

Middle name

Last name *

Preferred Name

Sex at Birth *

Gender *

Residence Status *

Ethnicity *

Date of birth *

Place of birth *

Country of birth *

Occupation

NHI (if known)

Contact Details

Email *

Address 1 *

Address 2

City *

Postcode *

Mobile/Phone *

Work Phone

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

I want my own account.

I want a joint account with an existing patient.

If joint account please provide details of existing patient.

Joint Patient's Name *

Joint Patient's Address 1 *

Joint Patient's Address 2

Joint Patient's City *

Joint Patient's Postcode *

Joint Patient's NHI

Next of Kin

First name *

Last name *

Mobile/Phone *

Relationship *

In Case of Emergency

First Name *

Last Name *

Mobile/Phone *

Relationship *

I am eligible to enrol because:

Documents *

A New Zealand Passport

OR

A New Zealand Birth Certificate

AND

A New Zealand Driving Licence

OR

An Overseas Passport

AND

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

Other visa attachment
(if required)

Services Card

Community Services Card Number

CSC Expiry Date

High User Health Card Number

HUHC Expiry Date

Health Information

GP Preference *

1. Are you allergic to anything, especially any drugs/medications? *

2. Do you drink alcohol? *

How many drinks per average week?

3. Please select your current smoking status *

How many per day do you/did you smoke?

Would you like help with quitting?

What year did you start smoking?

What year did you stop smoking?

4. Is there any other information that you would like us to know?

5. Please list any major illnesses/operations/diagnoses you have had

Do you have any family history of:

Do you have any family history of Diabetes *

Which relation of yours? *

How old were they at onset of disease? *

Heart Disease *

Which relation of yours? *

How old were they at onset of disease? *

Stroke *

Which relation of yours? *

How old were they at onset of disease? *

Bowel Cancer *

Which relation of yours? *

How old were they at onset of disease? *

6. Females only : What year did you have your most recent cervical smear?

Where did you have your last cervical smear (city/country)?

Was your recent cervical smear result (normal/abnormal/not sure)? please type

Have you ever had an abnormal cervical smear?

If yes, what year?

Medical History

Arthritis *

Date of diagnosis *

Asthma *

Date of diagnosis *

Screening History

Females: Mammogram *

Date of test *

Any abnormal results *

Females: Cervical Smears *

Date of test *

Any abnormal results *

Females: Bone Density *

Date of test *

Any abnormal results *

Males: PSA *

Date of test *

Any abnormal results *

Males and Females: Diabetes *

Date of test *

Any abnormal results *

Males and Females: Cholesterol *

Date of test *

Any abnormal results *

Immunisation History

Tetanus:

Date of last booster

Childhood Immunisations: Please provide all immunisation records including type and date.

Consent

I consent to receiving health check reminders (e.g. immunisation and smear reminders), notifications and appointment reminders by Text messaging (SMS)

I consent to medical centre sending me newsletter, surveys and information about services

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.

Current doctor and/or Practice name, and address (if not known, put "Unknown") *

Do you consent to transfering your medical records to us? *

Authority

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

Your Name *

Your Relationship to Applicant *

Your Mobile/Phone *

Please describe the basis or reason for acting as authority eg Parent of applicant under 16 *

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 www.wboppho.org.nz.

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.

Please sign in the box below *

Monday	08:00am – 5:30pm
Tuesday	08:00am – 5:30pm
Wednesday	08:00am – 5:30pm
Thursday	08:00am – 5:30pm
Friday	08:00am – 5:30pm
Saturday	08:30am – 12 noon (Emergency Clinic)
Sunday	08:30am – 12 noon (Emergency Clinic)
Public Holidays	08:30am – 12 noon (Emergency Clinic)

Age	Enrolled Patients
Children under 14	Free
Children under 14 with CSC	Free

14 – 17	$42.50
14 – 17 with CSC	$13.00

18 and over	$49.00
18 and over with CSC	$19.50

Opening Hours

Emergency Care

Fees

Health365

FAQs

New Patient Enrolment Form

Personal Details

Contact Details

Next of Kin

In Case of Emergency

I am eligible to enrol because:

Documents *

OR

AND

OR

AND

Services Card

Health Information

Do you have any family history of:

Medical History

Screening History

Immunisation History

Consent

Transfer of Medical Records

Authority

Agreement to the enrolment process

Terms & Conditions