Enrolment form

Enrolment form 注册表

Please fill the form in English only. 请使用英文填写表格

MrMrsMsMasterMissDrOther
Title 稱呼*
Other title 其他稱呼

Name 名*
Middle Name
Last name 姓*

Male 男Female 女Other 其他
please state your gender 请说明性别*

Today*

DayMonthYear
Date
Date of birth 出生日期*

DayMonthYear
Date
age
Name of authorised person as applicant is under 16
授权人姓名(由于申请人未满16岁)
Authorised person's name*

First NameLast Name
Authorised person's relationship 关系 *

Single 单身Married 已婚Divorced 离婚Separated 分居

Country of birth 出生国家*
Place of Birth 出生地*

NZ EuropeanMaoriChinese 华人SamoanTonganIndianOther 其他
Please state other ethnicity*

Address 地址*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Postal address 邮寄地址*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Occupation 职业*

Mobile phone 手机电话*
Home phone 住家电话
work phone 工作电话
Email 电邮*
example@example.com

Yes 同意No 不同意

Yes 同意No 不同意

Never 从不抽烟Yes 有Ex-smoker 前吸烟者
Quit date 戒烟日期*

DayMonthYear
Date

Next of kin 紧急联络人*

First Name 名Last Name 姓
Relationship 关系*
Phone 电话*
Email 电邮
example@example.com
Address 地址

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Yes 有No 没有
Community service card number 卡号
Community service card expiry 到期

DayMonthYear
Date

Yes 有No 没有
HUHC card number 卡号
HUHC expiry 到期

DayMonthYear
Date

I authorise the transfer of my medical records from the doctor I previously attended. I understand that my name will be removed from the register of my previous doctor.

本人授权并同意将以往的医疗纪录从原先的诊所转交到本诊所. 我了解我的名字将会在原先的诊所被抹除。
Yes 同意No 不同意Not applicable 不适用
Previous GP name 以前的医生*
Previous GP practice 以前的诊所*
You cannot register at this clinic unless you agree to transfer your medical notes to this clinic.

除非您同意将您的医疗记录转移到该诊所，否则您不能在该诊所注册。

- I am entitled to enrol because I am residing permanently in New Zealand
  The definition of residing permanently in NZ is that you intended to be a resident in New Zealand for at least 183 days in the next 12 months.
- I confirm that, if requested, I can provide proof of my eligibility
- 我有权利注册因为我在新西兰长期居住. 长期居住的定义为在往后的12个月里,至少有183天居住在新西兰。
- 我同意, 若被要求,我能够提供与我注册资格有关的凭据和资料
Yes 是No 不是
You cannot register at this clinic.

您不能在该诊所注册。

- I intend to use this practice as my regular and ongoing provider of primary health care services. 我将此诊所视为我基本和定期的基本医疗服务/家庭医生
- I understand that by enrolling with Dominion Medical Centre I will be enrolled with Auckland PHO, the Primary Health Organisation (PHO) this Medical Centre belongs to, and my name, address and other identification details will be included on both the practice and the PHO enrolment register. 我了解与此诊所注册, 我的注册资料会被提交到Auckland PHO (Primary Health Organisation), 奥克兰地区卫生局和卫生部
- I understand that if I visit another Medical Centre where I am not enrolled I may be charged a higher fee. 我明白我若去其他诊所就医, 将会被收取较高的费用
- I have been given information about the benefits and implications of enrolment with the PHO, and their contact details.我已被告知关于注册的含意和所带来的好处, 以及此间诊所提供的服务,和Auckland PHO的联系方式
- 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. 我已阅读并同意使用健康信息声明. 我在注册表格上提供的资料将用于确定获得公立资助服务的资格. 信息可能会在隐私法允许的情况下, 与其他政府机构进行比较
- 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.我明白此诊所参与了国家关于人民健康照护体验和他们整体健康是如何管理的调查。参加调查是自愿的以及所有的回答都是匿名的。我可以透过告知诊所，以拒绝或退出参与调查。此调查提供了重要信息去进步和改善医疗保健服务。
- I agree to inform the practice of any changes in my contact details and entitlement and/or eligibility to be enrolled.我了解若我的联系方式或注册资格有所改变, 我会通知此诊所, 以做更改
- Health and privacy statement 健康信息隐私声明
Yes 同意No 不同意
You cannot register at this clinic unless you agree to all the terms.

除非您同意所有条款，否则您不能在本诊所注册。

Camera 相机File upload 上传文件
Take a photo of your passport front page 拍一张护照首页的照片
Take a photo of your visa 拍一张签证照片
Upload a photo of your passport and visa 上传您的护照和签证照片

Cancelof

Signature 签名*

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Enrolment form 注册表