MyPractice Enrolment Form

My declaration of entitlement and eligibility

(for public funding)
I am residing permanently in New Zealand. (plan to be in New Zealand for at least 183 days in the next 12 months)
Please tick which eligibility criteria applies to you:
Please upload your evidence (i.e. Passport, Visa, Birth Certificate, proof of employment or study course, etc) - suggestion: scan and add, or take a photo and attach.

Browse Files

Cancelof
Take Photo of your evidence (i.e. Passport, Visa, Birth Certificate, etc)
Take Photo of your evidence - if you need another photo
Community Services Card
CSC number
CSC Expiry date

DayMonthYear
Date
Enrollment Type
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.
Name of previous Doctor
Name of previous Medical Practice
Previous Medical Practice Address (if known)
Signature
Date

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

First NameLast Name
Relationship:
Should be Empty:

Enrolment Form Hall Ave Medical Centre