The Airport Doctor Enrolment Form

The Airport doctors Enrolment Form

3/400 George Bolt Memorial drive, Auckland Airport Auckland, Phone: 09 2568655 Fax: 092568460, Email: reception@airportmedics.co.nz EDI: airoaks
- Name
  
  First NameLast Name
- Title
- Gender
- Gender diverse, please state if applicable
- Other names and preferred name
  
  Other names known by (eg. maiden name, etc) Preferred name
- NHI if known
- Date of birth
  
  DayMonthYear
  Date
- Place and Country of Birth
- Address
  
  Street Address
  
  Subur
  
  CityRegion
  
  Post CodeCountry
- Postal Address
  
  Same as above Different from above
- Postal Address
- Day Phone
  
  Area CodePhone Number
- Night Phone
  
  Area CodePhone Number
- Mobile number
  
  Area CodePhone Number
- Accepting Text to Your Mobile
- Email
  example@example.com
- Occupation
- Emergency Contact
  
  First Name   Last Name   Relationship
  
  Area Code   Phone Number
  
  Email
- Which ethnic Group Do You Belong To? Tick the space or spaces which apply to you
- Please specify Iwi
- Please specify ethnicity
- Smoking Status
- Quit Date
  
  DayMonthYear
  Date
- High User Health Card Holder
- High User Health Card Number
- High User Health Card Expiry Date
  
  DayMonthYear
  Date
- Community Services Card Holder
- Community Services Card Holder Number
- Community Services Card Holder Number Expiry Date
  
  DayMonthYear
  Date
- Eligibility criteria: I am eligible to enrol because I live in New Zealand^ and meet one of the following criteria:
- Please upload proof of identity eg. Passport or birth certificate. Alternatively you may send it separately via email: reception@airportmedics.co.nz
  
  Cancelof
- Please upload proof of eligibility eg. 2 year work visa or resident visa. Alternatively you may send it separately via email: reception@airportmedics.co.nz
  
  Cancelof
- Transfer of Records
- In order to get the best care possible. I agree to the transfer of my records from my previous doctor. I understand I will be removed from their practice register.
  
  Doctor's Name   First Name   Last Name
  
  Clinic name:Clinic Name
  
  Address: Street Address   Suburb   City      Post Code
  
  
  Phone: Area Code   Phone Number
- My agreement to the Enrolment Process (NB: Parent or caregiver to sign if you are under 16 years)
- Health Information Privacy
- I have read and understood the Enrolment Process and Health Information Privacy Statement, including how the practice collects health information directly from me and may receive health information about me from other health providers, agencies, whānau/caregivers, or other sources involved in my care, safety, enrolment, funding, screening, recall, audit, quality improvement, or legal obligations.*
- I have the authority to sign this enrolment form on behalf of:
- Signed by AUTHORITY
  An authority is the legal right to sign for another person if for some reason they are unable to consent on their own behalf.
  
  Fully name of Authority First Name   Last Name
  
  Relationship: Relationship
  
  Phone: Area Code   Phone Number
  
  Address:    Same as above    As below
  
  Street Address   Suburb   City   Post Code
  
  Detail the basis of authority:   eg. parent of a child under 16
- Signature
- Date
  
  DayMonthYear
  Date
- Should be Empty:

The Airport doctors Enrolment Form