Enrolment Form Devonport Family Medicine

If you want to register with our Health365 Patient Portal please tick the box below.

Each applicant must complete their own form and register with a unique email address. Once you have registered you will receive a confirmation email with your username and password.

The Patient Guide to the Portal will instruct you how to use Health365.

Health365 Patient Guide to the Portal

Emergency Contact

Relationship

Contact Number

Phone

Community Services Card

CSC number

CSC Expiry date

Date

Do you agree to receive text and email messages?

I've read and understand Devonport Medical Centre Account Policy (Please hover to read!)

Southern Cross Health insurance?

If yes, please note down Policy Number

Do you have a preferred Pharmacy for your scripts to go to?

Name and address please.

What brought you to our practice?

Name

First NameLast Name

Date of Birth:

Date

Are you allergic to any medications, food etc..?

Do you smoke?

Rows	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?

Alcohol/Any substance abuse?

Rows	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

Please list any regular medications you take.

Do you have any of the following medical problems? Or is there a family history of the following:

Rows	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

Do you have any other health, disability problems or inherited conditions? Please list:

Have you had any operations?

If yes please list:

When was your last Tetanus booster?

Are your childhood immunisations up to date?

Women: (those over 20 years & sexually active)

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

Patient Questionnaire signed :

Date

Appointments & Consultation Rules
Standard GP appointments are up to 15 minutes and focus on 1–2 key concerns. Additional charges may apply if consultations require more time. Longer appointments are available for specific needs, including:

• Driver licence medicals

• Mirena procedures

• Six‑week checks

• WINZ / ACC forms

• Insurance assessments

Full payment is expected at the time of your appointment.

Booking & Availability
Same‑day appointments are not guaranteed. Availability may vary seasonally and due to GP or nurse leave. Please book routine check‑ups and prescription renewals in advance.

Late Arrivals & Missed Appointments
If you arrive up to 5 minutes late, you may still be seen
If you arrive more than 5 minutes late, it is at the clinician’s discretion
Charges may apply for missed appointments

DNA Policy
A DNA (Did Not Attend) occurs when a patient does not attend a scheduled appointment or does not provide sufficient notice of cancellation. A DNA fee may apply, as the appointment time could have been offered to another patient.

For phone or video consultations, failure to answer at the scheduled time is considered a DNA
Phone and video consultations follow the same fees and rules as in‑person appointments
Appointment reminders are sent via SMS as a courtesy
If you receive a confirmation for an appointment you do not recall booking, please contact us as soon as possible
If concerns are not raised before the appointment time, a DNA fee may still apply

Communication & Responsibility
We communicate via call, email, SMS, and Health365.
Once a message has been successfully sent, it is considered delivered.

To help ensure nothing is missed, patients are encouraged to regularly check their messages and keep contact details up to date. While we are always happy to assist where possible, the practice is unable to take responsibility for messages that are sent but not accessed or read.

Communication & Contact
Our reception team aims to answer calls promptly. There may be a short wait if assisting other patients. Non Urgent:

General enquiries: receptionist@dfmdoctors.co.nz
Clinical questions & prescriptions: nurses@dfmdoctors.co.nz
Walk‑in appointments are not accepted

Prescription Requests
Standard prescription requests take 48–72 business hours
Urgent requests may incur an additional fee
Eligibility rules apply for 12‑month prescriptions
Email requests should be sent to nurses@dfmdoctors.co.nz
Please ensure you notify the practice of your pharmacy of choice.

Patient Portal (Health365)
If you opt in, the Patient Portal allows you to:

Request repeat prescriptions
View lab results
Message your care team
View upcoming appointments
If at anytime you update your email address, please notify reception.

Phone & Video Consultations
Phone and video consultations are suitable for some follow‑ups, medication reviews, and mild symptoms. Your GP may recommend an in‑person visit if required. If unsure, a nurse can help advise.

Accounts & Payments
Payment is expected on the day of your appointment
All services incur a fee, including phone, video, and administrative requests (forms, letters, referrals, prescriptions)
Accounts not paid within 14 days may incur a $10 late fee
Accounts should not exceed $100 outstanding without an agreed payment plan
Services, including online booking via Health365, may be temporarily restricted if an account remains overdue without arrangements

Payment Plans
If you are unable to pay in full, payment plans may be arranged:

Weekly payments, or
A lump sum followed by weekly payments
All new services must still be paid for at the time of appointment.

Referrals & Admin Work
Fees apply when GP time is used outside a standard consultation, including:

Private and hospital referrals
Forms and letters
Certificates, WINZ/ACC, insurance documentation
Prescription requests outside a consultation

We accept Southern Cross Easy‑Claim for eligible services.

Please:

Advise reception at check‑in if you are a Southern Cross member
Have your member card or app available
Please note:

Not all services are covered

Reception staff are unable to determine why a service may not be covered
For clarification regarding cover, please contact Southern Cross directly
If Easy‑Claim does not apply, payment is required at the time, and you may need to claim directly.

Keeping Details Updated
Please notify us if any of the following change:

Name
Address
Phone or email
Visa or eligibility status
Next of kin / emergency contact

Patient Privacy Policy
Under New Zealand privacy and health information laws, once a patient is 16 years of age or older, they are legally treated as an adult in relation to their health information.

This means we cannot share any personal or medical information with anyone else without your consent. This includes (but is not limited to):

Medical history and consultation details
Test results and investigations
Medications and prescriptions
Appointment information
Account or payment details
Unless we have legal authority or your explicit consent, we are only able to discuss your information directly with you, the patient.
If you would like another person (for example, a parent, caregiver, partner, or family member) to have access to your information, one of the following is required:

Legal authority (e.g. power of attorney, welfare guardian), or
Written consent from you
Written consent can be provided by emailing the practice and must include:

The full name of the person you are authorising
Their relationship to you
Exactly what they are permitted to access or do on your behalf
(e.g. receive results, discuss medications, book appointments)
How long this permission is valid for (if time‑limited)
Until this information is received and recorded, we are unable to share any details with anyone other than you.

Zero Tolerance Policy

Aggressive, abusive, rude or threatening behaviour toward staff will not be tolerated.

Please respect that our staff want to help you to the best of their ability.

Name

First NameLast Name

Date

I Acknowledge that I read and accept the Practice Policies above

Signature

Health Information Privacy statement

Your personal health information and how it is used.

CONSENT TO COLLECT PATIENT HEALTH INFORMATION Patients directly consent to health information (patient data) being collected when they sign an enrolment form with their family doctor or visit a GP practice.Your health information will be shared with others involved in your healthcare.This helps to improve care for individuals, and with the health information from many people collected together it can be used to improve health services, care for other patients and future generations as well as community wellbeing. Patient data is used for the following reasons: • To measure and improve the quality of healthcare• To understand the frequency and severity of common major health problems• To ensure that the differences in health status between different population groups are reduced• To identify health prevention and promotion strategies• To advocate for changes and improvement to health care funding and delivery• To support some health research, subject to approval by an ethics committee• To meet contract requirements with the Ministry of Health needed to obtain funding to reduce the cost of your GP visits

WHAT INFORMATION IS COLLECTED? • Information about you (name, date of birth, gender, address, ethnicity, citizenship, NHI number)• Information about your health and your medical conditions and measurements• Information about health services that are being provided to you e.g. medications, immunisations, health screening, lab results• Information about the financial transactions around consultation chargesInformation is not collected from your consultation notes (the progress notes your GP made on your file regarding your visits).

SECURITY & PRIVACY OF PATIENT DATA A PHO is a Primary Health Organisation. Patient data is sent securely to the PHO which stores this information in a data warehouse. The data provides a single source of information for practice clinicians. It is able to produce reports that help manage and improve services for patients.Some health information we collect and generate is stored electronically by cloud service providers located in Australia. This information may also be processed (but not stored) on cloud servers located in other overseas countries. This information is encrypted at all times and these providers comply with internationally recognised security standards.Information is also sent to the Ministry of Health to allocate funding subsidies which reduce the cost of GP visits.Robust protocols and processes have been developed for collecting and storing this data to make sure it is kept safe and protected.Our processes are fully compliant with the Privacy Act 1993 and HealthInformation Privacy Code.

CONSENT OPTIONS

If you do not consent to health information such as medical conditions, medications and lab results being collected, then you may ‘opt-off’ by letting your practice know.

Use of Artificial Intelligence (AI)

This practice may have staff that use AI tools to assist in providing healthcare services. All AI-assisted work is reviewed with human oversight to ensure their accuracy and appropriateness. AI will not be used for clinical decision-making or judgment. My health information will be used in accordance with legislative requirements and will not be shared with AI systems outside the practice without my consent. All data processed by AI tools will be handled securely and in compliance with data protection regulations. I will be informed about how AI tools are being used in my care and can ask questions or request more information at any time. I can also withdraw my consent at any point by notifying the practice.

DEVONPORT FAMILY MEDICINE - NEW PATIENT MEDICAL QUESTIONNAIRE

Practice Policies & Terms and Conditions

Final Declaration