Enrolment

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:

1. Personal details

Title

Family name *

First name(s) *

Preferred name

Other name(s) known by and/or maiden name

Date of birth *

Gender *

Account holder

2. Contact details

Physical address

Unit/house number

Street

Suburb

Town / city

Postcode

Home phone

Work phone

Mobile phone

Email address

Postal address

Unit/house number

Street

Suburb / rural delivery

Town / city

Postcode

Preferred contact methods

Secure email
Text
Landline
Cell phone
Post

Consent to use text messaging

3. Ethnicity

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

If Maori, please specify iwi

4. Residential status

Country of birth
If New Zealand is your country of birth, go to Q5

If you are not born in NZ are you a NZ resident?

Are you a refugee?

Are you on a working Visa?

5. Next of kin / emergency contact details

Title

Family name

First name(s)

Relationship

Unit/house number

Street

Suburb

Town / city

Postcode

Day phone

Mobile phone

6. Community health details

Community services card no

Expiry date

High user health card no

Expiry date

7. Employer

Name

Address

Town / city

Phone

Occupation

8. Smoking status

Smoking status is an important factor influencing health. Please tick the space that applies for those aged 15 and over:

If you currently smoke, would you like some help to quit?

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:

I am a New Zealand citizen OR

I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010

I am an Australian citizen or Australian permanent resident AND able to show I have been in New Zealand or intend to stay in New Zealand for at least 2 consecutive years

I have a work visa/permit and can show that I am able to be in New Zealand for at least 2 years (previous permits included)

I am an interim visa holder who was eligible immediately before my interim visa started

I am a refugee or protected person OR in the process of applying for, or appealing refugee or protection status, OR a victim or suspected victim of people trafficking

I am under 18 years and in the care and control of a parent/legal guardian/adopting parent who meets one criterion in one of the other options above

I am a NZ Aid Programme student studying in NZ and receiving Official Development Assistance funding (or their partner or child under 18 years old)

I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme

I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund

Patient information

Providing medical care for families since 1970

Enrolment

Required ID:

Physical address

Postal address