•  Phone: 094122924

  • Enrollment Form

  • When you and your family enrol with us, you pay significantly lower fees each time you visit any of our clinics. All you need is a Birth Certificate, Visa and Passport. There is no cost to enrol

  • Please Enrol me at*
  • Date of Birth*
     - -
  • Gender*

  •  -
  • Format: (00) 000-0000.
  • Format: (00) 000-0000.
  • Ethnicity Details - Which ethnic group(s) do you belong to? Tick the space or spaces which apply to you

  • 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)

  • You are not eligible for enrollment based on the information provided.

    Please contact the clinic at 094122924 for further assistance.

  • Please tick which eligibility criteria applies to you:
  • Attach Files
    Cancelof
  • Do you smoke
  • Community Services Card
  • CSC Expiry date
     - -

  • Enrollment

    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 have read and I agree with the Health Information Privacy Statement in the accompanying PHO information booklet. 

    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
     - -
  • Signed by
  • Should be Empty: