Phoenix Health Hub - new patient enrolement form

Enrolling is super easy - just complete this form and submit. Alternatively you can also enrol by visit our reception team at the Phoenix Health Hub. Please note if enroling in-person at the clinic you will need your birth certificate and/or passport. Thanks!
Phoenix Health Hub

9/166 Moorhouse Ave, Christchurch 8011

Ph: 03 260 1260

EDI: phoe66ix
Enrolment form

Enrolling with a general practice means you are entitled to funding which reduces the cost of your co-payment fees and subscription fees. Please note anyone over the age of 16 years must complete their own enrolment form.
I choose to enrol with this Phoenix Health Hub as my regular general practiceCasual or visitor only
Legal name

PrefixFirst NameMiddle NameLast Name
NHI number
-Office use only -
Date of birth*

MonthDayYear
Date
Country of birth
MaleFemaleOtherOther
Home address

Street Address

Street Address Line 2

SuburbCity

Postal / Zip CodeCountry
Mobile phone

Area CodePhone Number
Home phone

Area CodePhone Number
Work phone

Area CodePhone Number
E-mail
Occupation
Emergency contact

First NameLast Name
Emergency contact phone number

Area CodePhone Number
MāoriNew Zealand EuropeanSamoanCook IslandTonganNiueanChineseIndianOther
Iwi:
Yes, please provide number below and expiry dateNo
CSC number
Yes, please provide number below and expiry dateNo
High User Health Card number
High User Health Card expiry date

MonthDayYear
Date
SmokerNever smokedEx-smoker (less than 15mths ago)Ex-smoker (more than 15mths ago)
YesNo
Word of mouthGoogle searchAdvertisingOther
My declaration of entitlement and eligibility

(for public funding)
YesNo
(b) I hold a resident visa or a permanent resident visa (or a residence permit if issued before Dec 2010)(c) I am an Australian citizen or Australian permanent resident AND able to show I have been in New Zealand or intend to say in New Zealand for at least two consecutive years.(d) I have a work visa/permit and can show that I am able to be in New Zealand for at least two years (previous permits included)(e) I am an interim visa holder who was eligible immediately before my interim visa started.(f) I am a refugee or protected person OR in the process of applying for, or appealing refugee or protection status, OR a victim or suspected victim of people trafficking.(g) I am under 18 years of and in the care and control of a parent/legal guardian/adopting parent who meets one of the cirteria in clasues a-f above OR in the control of the Chief Executive of the Ministy of Social Development.(h) I am a NZ Aid Programme student studying in NZ and receiving Official Development Assitance funding (or their partner or child under 18 years old)(i) I am participating in the Ministry of Education Foreign Language Teaching Assistantship Scheme(j) I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund.
I confirm that, if requested, I can provide proof of my eligibility
Yes, please request transfer of my recordsNo transferNot applicable
Name of previous Doctor
Name of previous Medical Practice & Address (if known)
Please upload any supporting documents below

A photo or scanned copy of your birth certificate and/or passport is required for confirming identity and eligibility for funded health services. If you are not able to attach you files you can simply bring them into the clinic and our reception team can copy them.
File upload*

Browse Files

Cancelof
My agreement to the enrolment process*

NB. Parent or Caregiver to sign if you are under 16 years
I intend to use this practice as my regular and on-going 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 Pegasus Health Charitable Ltd PHO
(Primary Health Organisation) 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 agree with 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.
Signature*

Clear
Signature date
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:
e.g. Mother or father
Should be Empty:

Enrolment form