Waiora Wellness Pre-enrolment-Form-Final Standalone Only

Patient Enrolment Form

Waiora Wellness Centre

38 Richard Pearse Drive

Airport Oaks

Mangere

Auckland, 2022

0800 696 242

reception@waiora.health
Name*

TitleFirst Given NameMiddle/Other Given NameFamily Name
Mobile Phone*

022,027 etc...Phone Number
Home Phone Landline

09,022,etcPhone Number
Email Address*
If no email put N/A
Birth Date*

DayMonthYear
Date
Place of Birth*
Country of Birth*
GENDER*

MaleFemaleGender DiversePrefer not to say
Occupation*
Unemployed if not working
Your Residential Address*

Street Address

Suburb

CityState / Province

Postal Code
Postal Address: If the same as above just type as above in the address
Your Postal Address

Street Address

Suburb

CityState / Province

Postal Code
WHO IS YOUR EMERGENCY CONTACT?
Name*
Relationship*
Mobile (or other) Phone*

027,022, 09,etcPhone Number
TRANSFER OF RECORDS To get the best care possible, I agree to Waiora Wellness obtaining my records from my previous Doctor. I also understand that I will be removed from their practice register, as I can only be enrolled at one practice at a time in New Zealand.*

Yes please transfer my recordsNo TransferNot Applicable
Previous Doctor andor Practice Name*
Address Location*
Suburb
Ethnicity Details - Tick what applies to you*

New Zealand EruopeanMaoriCook IslandSamoanTonganNiueanChineseIndianOther
Other such as Dutch, Japanese, Tokelauan (Please state all)
If Maori what is your iwi?
If Maori what is your Hapu?
Concessional Information. Do you have:*

A Community Services CardA High user Health CardNone of the above
Health Questions: Please answer honestly and select what applies to you.
Current Height*
Put N/a if not known
Current Weight*
Put N/a if not known
Please select what applies to you*

Never Smoked or VapedPast Smoker (Quit more than 1 year ago)Recently Quit (Less than 1 year ago)Current Smoker/VaperI vape with nicotineI vape without nicotine
My Declaration of Entitlement and Eligibility

Please check all that apply to you.
I am entitled to enrol because:*

I am a permanent resident of New ZelansI am a New Zealand CitizenOther
I am not a New Zeland Citizen but I'm eiligible because:*

I hold a current resident visa or a permanent resident visaI am an Australian citizen or an Australian permanent resident and I'm able to show I have been in New Zealand or intend to stay in New Zeland for at least 2 consecutive yearsI have a current work visa/permit and can show that Iam legally able to be in New Zeland for at least 2 years (pervious permits/visas included)I am an interim visa holder who was eligible immediately before my interim visa startedI 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 traffickingI am under 18 years old and in the care and control of a parent/legal guardian/adopting parent who meets one criterion in the above clauses OR in the control of the Chief Executive of the Ministry of Social DevelopmentI am a NZ Aid programme student studying in NZ and receiving Offical Development Assistance funding (Or their partner or child under 18 years old)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 NZ University under the Commonwealth Scholarship and Fellowship fundOther
I confirm that if requested, I can provide proof of my eligibility*

Yes I can provide verification of my eligibility
I confirm that I will provide verification of my ID*

Yes I can provide verification of my identity
Services offered and pricing

Please note that these are the services offered at this time and are subject to change. Since you are pre-registering, please understand that we will confirm with you when our services are open for business, and then confirm when you are enrolled at our practice.
Agreement to the enrolment process

(Parent or Caregiver to sign if you are under 16 years)
- I intend to use this practice as my regular and ongoing provider of general practice / GP / 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) National Hauora Coalition, and my name, address, and other identification details will be included on the Practice, PHO, and National Enrolment Service Registers.
- I understand that I may be charged a higher fee if I visit another health care provider where I am not enrolled.
- I have been given information about the benefits and implications of enrolment and the services this practice and the PHO provide, along with the PHO's name and contact details.
- I have read and I understand 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.
- I understand that the Practice party participates in a national survey about people's health care experience and how their overall care is managed. Participation is voluntary, and all responses will be anonymous. I can decline the survey or opt out of it 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.
- I agree that signing below means I agree with all the statements listed above.
Signatory Details
Signature*

Powered by Jotform SignClear
Day Month Year
An authority has the legal right to sign for another person if for some reason they are unable to consent on their own behalf.

Signing for myselfAuthority to sign for someone else
Authority - Full Name
Your Relationship to the person your signing for e.g. Parent/Guardian/Agent
Contact Phone

09,022,etcPhone Number
Legal basis of authority eg parent of a child under 16 years of age
Should be Empty: