• ENROLMENT FORM

    ENROLMENT FORM

    OREWA MEDICAL CENTRE

  • ● 8D Tamariki Avenue, Orewa 0931 ● Phone: 09 426 5437 ● Fax: 09 427 8410 ● EDI: markjohn ●

  • Preferred Doctor:*
  • Date of Birth (Please double check)*
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  • Gender*
  • Gender at Birth*

  • Specify (optional)

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  • Ethnicity - Which ethnic group(s) do you belong to?*
  • How did you hear about Orewa Medical Centre*
  • Smoking causes health risks, do you Smoke?:*
  • Patient Portal - I would like to book appointments, order medications and view results online.*
  • I am happy to receive account statements and recalls via email and/or text message*

  • My declaration of entitlement and eligibility:

  • I am residing permanently in New Zealand (plan to be in New Zealand for at least 183 days in the next 12 months)*
  • I am a New Zealand Citizen*
  • If you are not a New Zealand Citizen, please tick which eligibility criteria applies to you*
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  • Please upload a clear photo of your identifcation (example below)

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  • Community Services Card*
  • CSC expiry date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Southern Cross

  • Enrolment

    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. 

  • 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.*
  • Date *
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    2 digit day, 2 digit month, 4 digit year
  • Signed by*

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