WMG Enrolment Form V5

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Enrolment Form
We are part of Wellington Medical Group, which means that our patients have a primary practice within our group but are also welcome to book routine or acute (i.e. non-long term conditions) appointments at our partner practices when this is more convenient.
Which practice would you like to be your primary practice? Click on the logo below to select a practice:*
Practice
Practice Number
Practice Email
Practice Address
Practice EDI
Practice Eligibility
Johnsonville Criteria
To enrol at Johnsonville Medical Centre, please select the whichever option best describes your situation:*

My residential address is in the Northern Suburbs (between and including Khandallah and Tawa). The address must have the postcode 6035, 6037, or 5028.I am the child or partner of a current Johnsonville Medical Centre patientNone of the above apply
Thorndon Criteria
To enrol at Thorndon Medical Centre, please select the whichever option best describes your situation:*

My residential address is in either Thorndon, Pipitea, Wellington Central, Kelburn, Northland, Wilton, Wadestown, Crofton Downs, Ngaio, Khandallah, or Kaiwharawhara.I am the child or partner of a current Thorndon Medical Centre patientI work in Thorndon or Wellington CentralI am a member of a diplomatic mission and primarily reside in the Wellington RegionNone of the above apply
Whitby Criteria
To enrol at Whitby Doctors, please select the whichever option best describes your situation:*

My residential address is in Whitby or Pāuatahanui, and I don't currently have an existing medical centre in the Porirua region.I am the child or partner of a current Whitby Doctors patientNone of the above apply
Practice Eligibility
Practice Eligibility Reason
Unfortunately we are only enrolling or registering patients at {practice} that meet one of the above criteria. You may be able to enrol at one of our other practices; please select from the practice images above to check their enrolment eligibility.

Please note that enrolling at our partner practices cannot be used to circumvent these criteria.
Enrolment Eligibility
Entitlement
We provide ongoing medical care and support for patients who are both eligible for government funding (enrolled patients) and not-eligble for government funding (registered patients).

Please answer the following questions to establish your eligiblity for funding:
Do you reside permanently in New Zealand?*

YesNo
You are considered to reside permanently in New Zealand if you intend to live in New Zealand for at least 183 days within the next 12 months.
Do you intend for us to be your regular and ongoing primary care provider?*

YesNo
Enrol Entitlement
Eligibility
Please select the situation which applies to you:

I am a New Zealand citizen (or am the child of or in the care of someone who is eligible under this situation).I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010), or am the child of or in the care of someone who is eligible under this situation).I am an Australian citizen or Australian permanent resident AND able to show that I have been in New Zealand or intend to stay in New Zealand for at least 2 consecutive years (or am the child of or in the care of someone who is eligible under this situation).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) (or am the child of or in the care of someone who is eligible under this situation).I am an interim visa holder who was eligible immediately before my interim visa started (or am the child of or in the care of someone who is eligible under this situation).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 (or am the child of or in the care of someone who is eligible under this situation).I am under the age of 18 and am in the care and control of a parent/legal guardian/adopting parent who meets one of the criteria above (not below)I am a NZ Aid Programme student studying in NZ and receiving Official Development Assistance funding (or am the child of or in the care of someone who is eligible under this situation).I am participating in the Ministry of Education Foreign Language Teaching Assistantship schemeI am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund.None of the above apply
Enrol Eligibility
Enrolment Test Complete
Enrolment Test Outcome
Based on your existing answers you are currently not entitled to government funding for your health care. If you think that this is incorrect and you should be able to enrol, please review the answers above or contact the practice on {practiceNumber} so that we can assist you.

You are still able to register with us for ongoing healthcare services. In this case, any services provided will be charged at our casual fee rates, however we will maintain your health record and will invite your for appropriate health screening based on your risk factors.

Alternatively, you may be able to see one of our GPs on a one-off casual basis when you need to be seen.
How would you like to proceed?*

Register as a patient who is not eligible for fundingRequest a casual consultation
Form Test Complete
Form Test Outcome
Thanks, please contact us on {practiceNumber} and we will confirm the availability of casual appointments. You do not need to complete the rest of this form.
Thank you for confirming your eligbility to enrol with us. Please continue with the enrolment form.
Supporting Documents
Because you have selected:

{EligibilityCriteria1}

Please provide a copy of your New Zealand passport. We will also need to verify photo ID on your first visit to the medical centre.

If you do not have a New Zealand passport, please provide 2 forms of ID (at least one with a photograph) and one of the following:
- your New Zealand Birth Certificate (or Cook Island, Niue or Tokelau birth certificate); or,
- your New Zealand Certificate of Citizenship; or,
- your Descent Registration Certificate; or,
- evidence you are currently getting a social security benefit (except emergency benefit)
Documents proving identity include:
- a driver licence
- an 18+ card
- an employment contract, a rental agreement, or
- letters addressed to you at your current address.
For children under the age of 18, a birth certificate is sufficient.
Because you have selected:

{EligibilityCriteria1}

Please provide a copy of your Australian passport or your valid Passport of your own nationality with a current resident visa (including a resident return visa) issued by the Government of Australia.
Because you have selected:

{EligibilityCriteria1}

Please provide a copy of your passport.
Thanks for confirming that you want to register with us as an unfunded patient. We need to verify your identity, so please upload a copy of your passport including photo. We will also need to verify this in person the first time you come and see us.
Upload your passport or ID documents here:*

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Please also provide proof that New Zealand will be your principal place of residence for two years or more (eg, work contract, house long-term lease, ownership, or mortgage). The two years is counted from the date you migrated to New Zealand.
Please also provide sufficient documentation to support your eligibility, for example, copies of applicable visas, evidence of extended residence, refugee status documents etc.
Upload your additional supporting documents here:*

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In order to complete this enrolment online, please upload copies/photos of these documents above. If you are unable to upload files, please come in and see us with your documents to compete the enrolment process.
Your Personal Details
Name
Family Name (surname) as per your passport*
First & Middle Name(s) as per your passport*
Full Name
Do you prefer to be addressed by a different name?*

YesNo
Preferred Name*
Who would you like to be your GP?

A specific personA male GPA female GPNo preference
Who would you like to request as your GP?
Please note that requests are subject to an individual GP's enrolment capacity, so requests are not guaranteed
Associated patients

Within our system we can associate patient records together. This doesn't give associated patents access to the patient record but means that we can easily look up associated patients when needed. This is commonly used for families, for example to help when booking appointments for children or older parents.

This information is required if you have selected that you are the child or partner of an existing patient.
Do you want your patient record to be associated with another patient, either existing or recently enrolled?*

YesNo
Please provide the following information for the person you would like us to associate your patient record with:
Full Name*
Date of Birth*

DayMonthYear
Date
Address
Current Residential Address*

State / Province
Do you have a different postal address?*

YesNo
Postal Address*

State / Province
Email Address
Phone numbers
Primary Contact Number (preferably mobile)*
Secondary contact number (optional)
Emergency Contact/Next of Kin
Full name of your emergency contact*
Relationship of your emergency contact to you*
Best contact number for your emergency contact*
Additional Information
Date of Birth*

DayMonthYear
Date
NHI number (if known):
Your NHI is 3 letters and 4 numbers long
Current Date

DayMonthYear
Date
Age Days
Calculated Years
Age Years
Gender*

MaleFemaleGender Diverse
What was your physiological sex at birth?*

MaleFemale
Country of Birth:*
Place of Birth:*
Occupation:*
Which ethnic group do you belong to?*

New Zealand EuropeanMaoriSamoanCook Island MaoriTonganNiueanChineseIndianOther
Please enter the name of your Iwi:
Do you consent to receiving information from us via text message and email?*

YesNo
Those with Community Services Cards and their descendants can receive additional funding for their health care.
Do you have a Community Services Card?*

YesNo
Please enter your Community Services Card number:*
Start Date:

MonthDayYear
Date
Expiry Date:*

MonthDayYear
Date
Our Online Health Portal
Portal Name
{portalName} is our online portal, which enables you to book appointments, order repeat scripts, and view your test results/notes. We highly recommend this is as a way to help manage your health.
Would you like to register for our online portal?*

YesNo
Please read and accept the following terms and conditions for using {portalName}:
1. Don’t use {portalName} for urgent issues or concerns. If you have any urgent concerns then either contact us by phone or come in to see our acute service.
2. All of the information you see in {portalName} comes via our internal practice system and is entered or reviewed by our clinical team, so some results may not be available straight away.
3. Don’t switch off the automatic notifications for your inbox. If you’re on the {portalName} system then in some cases this will be the first point of contact, and turning off the notifications will delay this contact.
4. Appointments booked through {portalName} are subject to the same terms and conditions as those booked over the phone. Appointments cancelled within an hour of the appointment may be subject to late cancellation fees.
5. There is no charge for accessing {portalName}, however the services offered (such as repeat prescriptions or messaging your GP) may incur fees. Information on any applicable fees is shown within {portalName}, however these are subject to change and any changes will apply if we have given notice of these changes via our website, even if this is not yet updated in {portalName}.
6. If you see any information on {portalName} which you think is incorrect, please get in touch so we can review and correct the information.
7. If you have any technical difficulties with {portalName} please contact us in the first instance. We may need to raise some issues with our supplier, but your information is encrypted and is not available to their support team.
Do you accept these terms and conditions for the use of our online portal?*

Yes
Previous GP or Medical Centre
Do you have a previous medical centre or GP?*

YesNo
Please enter the name of your previous medical centre or GP here:*
Do you authorise us to obtain your medical records from your previous medical centre or GP?*

YesNo
Health Information
Do you have any known medical allergies?*

YesNo
Please provide more information:*
Have you or have you had a significant illness/surgery/medical condition?*

YesNo
Please provide more information:*
Family History
Please select any of the following that apply to you:

I have a family history of diabetesI have a family history of asthmaI have a family history of strokes under the age of 50I have a family history of mental health conditionsI have a history of heart attacks under the age of 50I have a family history of cancerI have a family history of high blood pressureI have a family history of high cholesterol
For each of the above that you have selected, where possible please advise which family members by relationship and their age when diagnosed (e.g. mother: diabetes aged 45, grandfather: heart attack aged 48)
Smoking History
What is your current smoking status?*

Never smokedEx-smokerCurrent smoker
Congratulations on quitting smoking and staying quit! While smoking is the past is important for us to know, quitting smoking is (along with quitting vaping) by far the best thing that you could have done for your health.

If you're struggling with staying quit and would like some help, let us know and we'll do whatever we can to help.
When did you stop smoking?*
While we know that smoking is a significantly addictive habit, quitting smoking is (along with quitting vaping) by far the best thing that you can do for your health. If that's something your interested in and would like some support, we're here to help.
Would you like any help in starting to quit smoking?

YesNo
What is your current vaping status?*

Never vapedEx-vaperCurrent vaper
Congratulations on quitting vaping and staying quit! While vaping is the past is important for us to know, quitting vaping is (along with smoking) by far the best thing that you could have done for your health.

If you're struggling with staying quit and would like some help, let us know and we'll do whatever we can to help.
When did you stop vaping?*
What type of vaping do you do?*

I vape with nicotineI don't vape with nicotine
While we know that vaping is a significantly addictive habit, quitting vaping is (along with quitting smoking) by far the best thing that you can do for your health. If that's something your interested in and would like some support, we're here to help.
Would you like any help in starting to quit vaping?

YesNo
Brief Smoking Advice provided

YesNo
Alcohol Consumption
How many standard drinks of alcohol do you drink per week?*
What type of alcohol do you normally consume?
Immunisations
If possible, please provide with your Tamariki Ora Well Child book as this will include all of your vaccinations.
Do you know the date of your last tetanus injection?*

YesNo
Date of your last tetanus injection:*

DayMonthYear
Date
Do you know the date of your last measles injection?*

YesNo
Date of your last measles injection:*

DayMonthYear
Date
Do you have any Non-New Zealand Immunisation records?*

YesNo
Would you like to upload these here or provide them to us later?*

Upload them nowProvide later
Please upload your non-NZ immunisation records here:*

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Cervical Screening
Do you want us to be your cervical screening organisation?*

YesNo
Who would you like to be your nominated cervical screening organisation?
Have you had a hysterectomy (surgical removal of the womb)*

YesNo
Mammograms
Date of your last mammogram (if known):

DayMonthYear
Date
Were the results of this mammogram normal?

YesNo
Do you give us permission to access your mammogram history and for future results to be sent to us?*

YesNo
Mammogram consent
Enrolment Agreement

To enrol with us please read and understand the Health Information & Privacy Statement and the Benefits and Implications of Enrolment and ensure that you agree to the below:

I choose to enrol with {practice} (part of Wellington Medical Group) as my regular and on-going provider of general practice/GP/primary health care services. I understand that if I visit another provider where I am not enrolled I may be charged a higher fee.

I confirm that I am entitled to enrol with {practice} (part of Wellington Medical Group) as I am residing permanently in New Zealand and {EligibilityCriteria1}. I agree to inform {practice} of any changes in my contact details and entitlement and/or eligibility to be enrolled.

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 Tu Ora Compass Health to be my PHO (see above).

I understand that by enrolling with {practice} (part of Wellington Medical Group) I will be included in the enrolled population of Tu Ora Compass Health and my name, address, and other identification details will be included on the relevant 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 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 {practice} participates in an optional anonymous national survey about people’s health care experience and how their overall care is managed, which provides important information that is used to improve health services. I can decline the survey or opt out of the survey by informing the Practice.
I agree to the above Enrolment Agreement*

Yes
Terms of Payment

For enrolled patients we prefer to receive payment for services on the day, otherwise we expect to receive payment within 10 days.

For registered and casual patients, payment is required on the day (unless otherwise agreed) and may be required prior to your appointment.

Accounts not paid within this timeframe will attract monthly administration charges and other credit controls, unless you contact us to make prior arrangements. Please contact the practice on {practiceNumber} or {practiceEmail} if you would like to make any alternative arrangements.

Accounts which remain unpaid may be sent to debt collection, even if you cease your enrolment with us, and you will be responsible for any associated debt collection costs. Continued non-payment may also result in your enrolment being cancelled.
I accept the terms of payment*

Yes
Signing required
All patients over the age of 16 must sign for their own medical records.
Who is signing this form*

The person enrolling/registeringSomeone with authority to sign on behalf of the person enrolling/registering
What is your relationship to the person enrolling/registering?*
Signed:*

Clear
Date of Signature*

DayMonthYear
Date
Details Complete
Signed
Should be Empty:

Enrolment Form

Johnsonville Criteria

Thorndon Criteria

Whitby Criteria

Enrolment Eligibility

Supporting Documents

Your Personal Details

Name

Associated patients

Address

Phone numbers

Emergency Contact/Next of Kin

Additional Information

Our Online Health Portal

Previous GP or Medical Centre

Health Information

Family History

Smoking History

Alcohol Consumption

Immunisations

Cervical Screening

Mammograms

Enrolment Agreement

Terms of Payment