Enrolment Form

Bayside Medical Practice, 6/17 Patteson Avenue, Mission Bay, Auckland 1071

EDI #:bay537sd (P) 09 5286152 (F) 09 5218417 (E) reception.baysidemedical@gmail.com

Name

First Name Last Name

Date of Birth

Date

Place of Birth

Country of Birth

Gender

Male Female

Occupation

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Postal Address (if different from above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Mobile Phone

Area Code Phone Number

Home Phone

Area Code Phone Number

Email

example@example.com

Do you agree to receive emails for communication and updates?

Yes No

Emergency Contact - Name

Emergency Contact - Relationship

Emergency Contact - Email

example@example.com

Transfer of 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.

Yes, please request transfer of my records No transfer Not applicable

Name of previous Doctor

Name of previous Medical Practice

Previous Medical Practice Address (if known)

Do you agree to receive text messages?

Yes No

Ethnicity Details - Which ethnic group(s) do you belong to? Tick the space or spaces which apply to you

New Zealand European Maori Samoan Cook Island Maori Tongan Niuean Chinese Indian

Community Services Card

Yes No

CSC Expiry date

Date

CSC number

Do you smoke?

Yes No (Ex -smoker) Never