Enrolment Form Silverstream Medical Centre

My declaration of entitlement and eligibility

Yes - fill in eligibility belowNo - do not fill in eligibility below

a. I am a New Zealand citizen.

b. I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010).c. 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.d. 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).e. I am an interim visa holder who was eligible immediately before my interim visa started.f. 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.g. I am under 18 years and in the care and control of a parent/legal guardian/adopting parent who meets one criterion in clauses a-f above OR in thee control of the Chief Executive of the Ministry of Social Developmenth. 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. I am participating in the Ministry of Education Foreign Language Teaching Assistantship schemej. I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund

Yes

I read and agree to the Terms of Trade (available to view on our website).

Please upload your evidence (i.e. for New Zealand citizens over 18 years old, either New Zealand Passport or Birth Certificate and 2 forms of supporting identity information, one with a photo ( driver's license, community services card). For Non New Zealand citizens Passport and Visa) - suggestion: scan and add, or take a photo and attach. *

Browse Files

Take Photo of your evidence (i.e. Passport, Visa, Birth Certificate, etc)

Take Photo of your evidence - ( If on temporary Visa, include copy of Customs stamp with date of entry to New Zealand)

NoYes My agreement to the enrolment process Parent or Caregiver to sign if you are under 16 years * I intend to use this practice as my regular and on-going provider of general practice/GP/health care services. * I understand that by enrolling with this practice, I will be included in the enrolled population of Pegasus Health Charitable Ltd PHO (Primary Health Organization) 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 enrolled, I may be charged a higher fee. * I have been given information 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 agree with the Use of Health Information Statement. (Links to the information under "enrolment" on the website) . * The information I have provided on the Enrolment form will be used to determine eligibility to receive publicly-funded services. Information may be compared with other government agencies but only when permitted under the privacy act. * 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 enrolled.

I read and agree to the Terms of Trade (available to view on our website).

Signatory Details*

Date of signature*

Date

Self-signingAuthority

An authority has the legal right to sign for another person if for some reason they are unable to consent on their own behalf.

Authority Details: (where signatory is not the enrolling person)

Name of authority:

First NameLast Name

Relationship:

Phone Number

Area CodePhone Number

Basis of authority (i.e. parent of a child under 16 years of age, parent or spouse with dementia, etc)

Yes

2. Please your regular medications*

3. Please list any surgeries

4. Please list any allergies

5. Do you drink alcohol? if so what is the average per week

6. Are you a smoker, present or past? If yes, how many packets /day

By signing this form, you ackowledge that you have read and agree to the terms of trade hereafter. Please download New Patient Questionaire, Complete and email to reception@silverstreammedicalcentre.co.nz

Terms of Trade

The following Terms of Trade apply to services provided by Silverstream Medical Centre. By signing this document, you agree to the terms and conditions outlined below:

Appointments are 15 minutes long. For more than two simple concerns or one complex issue, patients must book a double appointment.

Patients accept that if no appointments are available or if clinically appropriate, they may be directed to an after-hours or emergency provider.

A 30 minutes new patient appointment is a requirement of the enrolment process. Failure to attend the new patient appointment incurs the full fee. Repeated non attendance may result in disenrollment.

If a patient arrives late for an appointment, they may be asked to reschedule. A fee will be charged.

At times, due to unforeseen circumstances, appointments may need to be rescheduled, sometimes at short notice.

Our fees are available upon request. These charges reflect:

· The time spent

· The complexity of treatment

· The cost of running a medical practice

· The funding available from the government, public agencies, and other sources

Unless prior arrangements are made, all services must be paid for on the date of service.

If cost is a barrier to accessing care, please speak with your doctor or the Practice Manager to discuss payment options.

Payment is accepted by cash, eftpos, credit card, internet banking or automatic payment.

If payment on the day is not possible, it must be made within 7 days of the invoice or as agreed with the doctor or Practice Manager.

Failure to meet agreed payment terms may result in referral to a debt collection agency. All associated recovery costs will be charged to the patient. This may affect your credit rating.

Silverstream Medical Centre may update the Terms of Trade from time to time. Notification will be provided on your invoice; continued use of services constitutes acceptance of changes.

Code of Conduct for Patients

To maintain a safe and respectful environment for staff, patients, and visitors, Silverstream Medical Centre expects all patients and accompanying persons to adhere to our Code of Conduct.

By enrolling with our practice, patients acknowledge that when capacity is reached, they may be referred to after-hours services for care.

The following behaviours are considered unacceptable and will not be tolerated:

· Repeated failure to attend appointments without notifying the practice*

· Failure to pay for services without prior arrangement

· Harassing, offensive, or intimidating statements, including verbal, written, or electronic threats

· Swearing or using abusive language

· Throwing objects or climbing on furniture

· Verbal threats to harm individuals or destroy property

· Intentional damage to equipment or property

· Attempting to intimidate or harass others

· Racial, cultural, or sexual slurs or derogatory remarks

· Possession of firearms or other weapons

· Physical assault, arson, or inflicting bodily harm

· Recording staff of the medical centre without prior agreement.

If you are subjected to or witness any of these behaviours, please report it to a staff member immediately.

Non-compliance with this Code of Conduct may result in immediate removal from the facility and/or discharge from the practice. Adults are expected to supervise children in their care. Any damage caused to the property will be charged.

*Missed Appointments

Late Cancelation / ( did not arrive) DNA. If you cancel within 2 business hours of an appointment, do not show up, a fee equivalent to your appointment charge will be charged.

Repeated DNA – Your enrolment will be reviewed and may be discontinued.

Acknowledgement and Agreement
I acknowledge that I have read and understood the Terms of Trade and Code of Conduct outlined above. I agree to comply with these policies as a condition of my enrolment at Silverstream Medical Centre.

Patient/Representative name: ____________________________________

Request to Enrol Form