Enrol with Ponsonby Doctors

Welcome to Ponsonby Doctors!

Before you begin filling out the enrollment form, please ensure you have the necessary identification ready.

In New Zealand, this typically includes a copy of your passport and, if applicable, any relevant residency or work visa documents. A photo of these documents taken with your cellphone is acceptable. Having these items available will help you complete the form smoothly and expedite your registration process.

We look forward to assisting you with your healthcare needs.

Personal Information

IMPORTANT: The information provider here must match the information on your passport
Title*
Title
First Name(s)*
As per passport
Surname(s)*
As per passport
Middle Name(s)
As per passport
Preferred Name
Usual Residential Address
Address*

Street Address

Street Address Line 2

CityRegion

Postal / Zip Code
Different Postal Address

Different postal address
Contact Details
Primary Number*
Mobile preferred
Secondary Number

Declaration of Entitlement and Eligibility
Entitlement*

I am entitled to enrol because I permanently reside in New Zealand (This means I intend to be in New Zealand for at least 183 days in the next 12 months).
I am eligible to enrol because:*

I am a New Zealand citizenI hold a resident visa or 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 yearsI have a current work visa/permit and can show that I am legally able to be in New Zealand for at least 2 years (Previous visa/permits included)I am under 18 and in the care and control of a parent/legal guardian/adopting parent who meets one criterion above.
Please Note: If you don’t meet any of the eligibility criteria, please contact the practice directly to discuss other options.
Proof of Eligibility
Upload your Passport and appropriate ID to prove your eligibility to enrol. Please check this list of appropriate IDs to ensure the correct ID is uploaded.

If your ID is incorrect or missing documents we can't progress your enrolment. NB: drivers licence is not sufficient; overseas passports need to have a valid 2 year Visa attached.

Max upload size: 2MB. Accepted files jpeg, png, doc, docx and PDF
File Upload*

Max upload size: 2MB. Accepted files jpeg, png, doc, docx and PDF
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Enrolment Agreement
Your agreement to the enrolment process (Parent, Guardian or Caregiver to sign if under 16 years). Please read and understand the Health Information & Privacy Statement and the Information on Enrolling With A General Practice

I choose to enrol with this practice as my regular and on-going provider of general practice / GP / primary health care services.
- I understand that by enrolling with this practice I will be included in the enrolled population of this practice’s Primary Health Organisation (PHO): , and my name address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers. Personal details and clinical notes may be shared with other Health Providers, or third party requests as part of my healthcare e.g ACC, Insurance Company requests, Ministry of Health, WINZ etc.
- 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 understood the requirements of enrolling with one PHO and choose this Practices’ PHO to be my PHO.
- I have read and agree with the Health Information & Privacy 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.
Acceptance*

I accept the above enrolment agreement
Signatory*

Self-signingParent/Guardian/Caregiver
Signature*

Powered by Jotform SignClear
Once you have submitted your enrolment form you will also be asked to complete a medical questionnaire. It is important that we have all the necessary medical information about your health to provide you with the best healthcare.
Should be Empty:

Personal Information

Usual Residential Address

Contact Details

Birth Details

Emergency Contact Person / Next of Kin

Parent/Guardian/Caregiver

Ethnicity

Smoking / Vaping

Booking Appointments & Communication

Transfer of Records

Declaration of Entitlement and Eligibility

Proof of Eligibility

Enrolment Agreement