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Patient information

Providing medical care for families since 1970


Please complete the form below.  When you have submitted the form, please print it off and bring your copy to the medical centre to sign (if you do not have a printer we can do that for you). 

You must bring in the following ID below for your enrolment form to be processed.

Required ID:

The following Identification is required

  • NZ Passport
  • Birth Certificate or
  • Current Community Services Card


1. Personal details
2. Contact details

Physical address

Postal address

3. Ethnicity

Which ethnic group do you belong to? (you may select up to three ethnicities):

4. Residential status
5. Next of kin / emergency contact details
6. Community health details
7. Employer
8. Smoking status
9. Signed authority

I intend to use Te Awamutu Medical Centre as my regular and ongoing provider of general practice / GP / First Level primary health care services.
I am entitled to enrol because I am residing permanently in New Zealand and meet one of the following eligibility criteria: