Enrolment Form Devonport Family Medicine

DEVONPORT FAMILY MEDICINE

2 FLEET STREET, DEVONPORT 0624

Ph 09 445 0528

receptionist@dfmdoctors.co.nz

EDI: dvnprtfm

Dr Pieter Veenhuijsen NZMC 21634

Dr Kosar Kheirabi NZMC 72982

Dr Nawar Mansoor NZMC 84390

Enrolment Type*

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

NHI number

-Office use only-

Full Name*

PrefixFirst NameMiddle NameLast Name

Date of Birth*

DayMonthYear

Gender*

MaleFemaleOther

Place of Birth*

Country of Birth*

Home Address*

Street

Suburb

City

Postal CodeCountry

Mobile Phone

MobilePhone Number

Home Phone

Area CodePhone Number

Email

example@example.com

Work Phone

Area CodePhone Number

Occupation

Ethnicity Details - Which ethnic group(s) do you belong to?*

Iwi

If applicable

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)*

YesNo

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

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

Transfer of Records - In order to get the best care possible, I agree to Devonport Family Medicine obtaining my records from my previous Doctor. I also understand that I will be removed from their practice register.*

Yes, please request transfer of my recordsNot applicable

Name of previous Doctor

Name of previous Medical Practice & Address (if known)

Signature*

Date

Signed by*

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:

Enrolment
I understand that by enrolling with this practice I will be enrolled with the Primary Health Organisation (PHO) . 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 have read and I agree with the Health Information Privacy statement (below). I agree to inform the practice of any change in my eligibility.

	YES	NO	If YES how many/day	Extra information you want us to know?
Do you smoke
Have you ever smoked?
If yes, would you like help to quit smoking?
Do you vape?

	Yes	No	If yes, on average how much/week and what type?	Extra information you want us to know?
Do you drink alcohol?
Do you have any substance abuse problems

	SELF	Family
Diabetes
High blood pressure
Heart disease or problems
Heart attack < 60 year
Asthma
Other lung or respiratory disease or problems
Kidney disease or problems
Liver disease or problems
Bowel disease or problems
Joint disease or problems, arthritis
Depression and/or anxiety
Other mental health illnesses
Blood Clot
Stroke
High Cholesterol
Migraine
Epilepsy
Breast cancer
Other cancer
Rheumatic Fever
Tuberculosis (TB)
Eczema
Hay Fever
Glaucoma

	Yes	No	When
When was your most recent cervical smear
Have you ever had an abnormal smear?
Have you ever had a mammogram? (>40y)

DEVONPORT FAMILY MEDICINE - NEW PATIENT MEDICAL QUESTIONNAIRE