I intend to use this practice as my regular and ongoing 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 this practice’s Primary Health Organisation (PHO) [Western Bay PHO], 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 I understand the Use of Health Information Statement. 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.

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):

We can help if you do not have the ID needed, please call us on 07 573-0091

Ngā mihi nui, we look forward to getting to know your health needs. Mahitahi – working together to help you be well, get well and live well.