Enrolment Form
This is a request to enrol and does not automatically lead to enrolment
Dr Promila Pal
NZMC : 23516 edi: selwyn
Dr Jitendra Pal
NZMC : 23054 edi: selwyn
Name
First Name
Last Name
Gender
*
Male
Female
Email
*
example@example.com
Mobile Phone
eg "021xxxxxxxxx"
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Country of Birth
*
Place of Birth
Ethnicity
*
NZ European
Māori
Samoan
Cook Islands Maori
Tongan
Niuean
Chinese
Indian
Other
Other Ethnicity (optional)
such as South African, Dutch, Fijian, Tokelauan,
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I am 16 yrs old and over
*
Yes
No
I give permission for my existing GP to transfer my patient notes
*
Yes
Not applicable
My Existing GP / Medical Practice
Write name of doctor, or name of practice
I agree to communcation by Email / SMS and participate in Surveys
*
Yes
No
Eligibility
I am eligible to enrol because I live in New Zealand and meet one of the following criteria:
*
I am a New Zealand citizen
I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010
I am an Australian citizen or Australian permanent resident AND able to show I have been in New Zealand or intend to stay in New Zealand for at least 2 consecutive years
I have a work visa/permit and can show that I am able to be in New Zealand for at least 2 years (previous permits included)
I am an interim visa holder10 who was eligible immediately before my interim visa started
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
I am under 18 years and in the care and control of a parent/legal guardian/adopting parent who meets one criterion in clauses above
I am a NZ Aid Programme student studying in NZ and receiving Official Development Assistance funding (or their partner or child under 18 years old
I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme
I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund.
My Agreement to the enrolment process
NB: Parent or caregiver to sign if you are under 16 years. Tick ALL boxes one by one
*
I intend to use this practice as my regular andongoing provider of general practice / GP / First Level primary health careservices
I understand that by enrolling with this practice I will be enrolled with the Primary Health Organisation (PHO) this practice belongs to, and my name address and other identification details will be included on both the Practice, PHO and National Enrolment Service 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 and the services this practice and PHO provides, and their contact details.
I understand that the Practiceparticipates in a national survey about people’s health care experience and howtheir overall care is managed. Taking part is voluntary and all responses willbe anonymous. I can decline the survey or opt out of the survey by informingthe Practice. The survey provides important information that is used to improvehealth services.
I agree to inform the practice of any changes in my eligibility
I will get a copy of "Use of Health Statement"
Signature
*
Your passport plus the revevant Visa can be uploaded here. Proof of Eligibility is not required if you are NZ Citizen.
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