DO NOT USE IM Enrolment Form

Enrollment

I choose to enroll with this practice as my regular general practiceCasual or Visitor Only

Please read the following important information:

I understand that by enrolling with this practice I will be enrolled with the PHO -Primary Health Organisation ProCare. My name, address and other identification details will be included on both the practice and PHO enrolment registers.
I understand that if I visit another 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 with the PHO and their contact details.
I agree to inform the practice of any change in my eligibility.
I have read and I agree with the Health Information Privacy Statement in the accompanying PHO information sheet.

YES

Yes, please request transfer of my recordsNo transferNot applicable

Name of previous Doctor

Name of previous Medical Practice

Previous Medical Practice Address (if known)

Signature*

Date *

PatientAuthorised Person (Parent or Caregiver to sign if under 16 years)

Name of authorised Person with legal right to sign for this patient:

First NameLast Name

Relationship: