Khadder Enrolment Form 29/07/2025
  • Mangere Health Centre

    Address: 6 Waddon Place, Mangere, Auckland, 2022

    Phone: 09 2550600

    Email: admin@mhc.net.nz 

    Website: https://www.mangerehealthcentre.co.nz/

    Practitioner: Dr Khadder Aweidah

    NZMC: 22485

    EDI: manghc2

  • Enrolment Form

  • Ethnicity Details - Which ethnic group(s) do you belong to? Tick the space or spaces which apply to you:*
  • Do you require a translator for your appointments?
  • What are your preferred gender pronouns?
  • Contacts

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  • Emergency Contact

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  • General Health Questionnaire

    We would appreciate it if you could fill in the information below so that it can be added to your patient notes
  • Is this form for a child:*
  • Is your child up to date with all their childhood vaccinations?
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  • Smoking Status Update

  • Being smokefree is one of the best things you can do for your health and the health of your family and friends.

  • How would you describe your Smoking Status?*
  • Did you used to be a smoker?
  • Congratulations on quitting smoking. Please let us know when you successfully stopped smoking:*
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  • Alcohol Status Update

  • How often do you drink alcohol?*
  • How many units do you drink in each occasion?*
  • How often do you have 6 or more units of alcohol?*
  • The standard drinks measure is a simple way for you to work out how much alcohol you are drinking. It measures the amount of pure alcohol in a drink. One standard drink equals 10 grams of pure alcohol.

    330 ml can of beer @ 4% alcohol = 1 standard drink
    100 ml glass of table wine @ 12.5% alcohol = 1 standard drink
    335 ml bottle of RTD spirits @ 8% alcohol = 2.1 standard drinks
    750 ml bottle of wine @ 13% alcohol = 7.7 standard drinks
    1000 ml bottle of spirits @ 47% alcohol = 37 standard drinks
    3 litre cask of wine @ 12.5% alcohol = 30 standard drinks
    Cocktails can contain as much alcohol as 5 or 6 standard drinks, depending on the recipe.

    Learn about alcohol recommendations at Ministry of Health NZ website 

  • My declaration of entitlement and eligibility

    (for public funding)
  • I am residing permanently in New Zealand. (plan to be in New Zealand for at least 183 days in the next 12 months)*
  • Please tick which eligibility criteria applies to you:*
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  • Do you have a Community Services Card?
  • Community Services Card Expiry Date:
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  • Enrolment

  • Enrolment Type*
  • Please read the following important information

    Enrolment Process and Health Information Privacy Statement

    Use and confidentiality of your health information 

    Your privacy and confidentiality will be fully respected. This fact sheet sets out why we collect your information and how that information will be used.

    Purpose

    We collect your health information to provide a record of care. This helps you receive quality treatment and care when you need it.

    We also collect your health information to help:

    • keep you and others safe 
    • plan and fund health services
    • carry out authorised research
    • train healthcare professionals
    • prepare and publish statistics
    • improve government services

    Confidentiality and information sharing (Health Information Privacy Statement)

    Your privacy and the confidentiality of your information is really important to us.

    • Your health practitioner will record relevant information from your consultation in your notes.
    • Your health information will be shared with others involved in your healthcare and with other agencies with your consent, or if authorised by law.
    • You don't have to share your health information, however, withholding it may affect the quality of care you receive. Talk to your health practitioner if you have any concerns.
    • You have the right to know where your information is kept, who has access rights, and, if the system has audit log capability, who has viewed or updated your information.
    • Your information will be kept securely to prevent unauthorised access.
    • We may receive information about you from other sources (including healthcare providers, family/whānau, or other organisations involved in your care or support). Where required, we will take reasonable steps to inform you that this information has been received.

    Information quality

    We're required to keep your information accurate, up-to-date and relevant for your treatment and care.

    Right to access and correct

    You have the right to access and correct your health information.

    • You have the right to see and request a copy of your health information. You don't have to explain why you're requesting that information, but may be required to provide proof of your identity. If you request a second copy of that information within 12 months, you may have to pay an administration fee.
    • You can ask for health information about you to be corrected. Practice staff should provide you with reasonable assistance. If your healthcare provider chooses not to change that information, you can have this noted on your file.

    Many practices now offer a patient portal, which allows you to view some of your practice health records online. Ask your practice if they're offering a portal so you can register.

    Use of your health information

    Below are some examples of how your health information is used.

    • If your practice is contracted to a Primary Health Organisation (PHO), the PHO may use your information for clinical and administrative purposes including obtaining subsidised funding for you.
    • Your District Health Board (DHB) uses your information to provide treatment and care, and to improve the quality of its services.
    • A clinical audit may be conducted by a qualified health practitioner to review the quality of services provided to you. They may also view health records if the audit involves checking on health matters.
    • When you choose to register in a health programme (eg immunisation or breast screening), relevant information may be shared with other health agencies.
    • The Ministry of Health uses your demographic information to assign a unique number to you on the National Health Index (NHI). This NHI number will help identify you when you use health services.
    • The Ministry of Health holds health information to measure how well health services are delivered and to plan and fund future health services. Auditors may occasionally conduct financial audits of your health practitioner. The auditors may review your records and may contact you to check that you received those services.
    • Notification of births and deaths to the Births, Deaths and Marriages register may be performed electronically to streamline a person's interactions with government.

    Research

    Your health information may be used in research approved by an ethics committee or when it has had identifying details removed.

    • Research which may directly or indirectly identify you can only be published if the researcher has previously obtained your consent and the study has received ethics approval.
    • Under the law, you are not required to give consent to the use of your health information if it's for unpublished research or statistical purposes, or if it's published in a way that doesn't identify you.

    Complaints

    It's OK to complain if you're not happy with the way your health information is collected or used.

    Talk to your healthcare provider in the first instance. If you are still unhappy with the response you can call the Office of the Privacy Commissioner toll-free on 0800 803 909, as they can investigate this further.

    For further information

    Visit https:New Zealand Legislation to access the Health Act 1956, Official Information Act 1982 and Privacy Act1993

    The Health Information Privacy Code 1994 is available at https://www.privacy.org.nz/. You can also use the Privacy Commissioner's Ask Us tool for privacy queries.

    A copy of the Health and Disability Committee's Standard Operating procedures can be found at https://ethics.health.govt.nz/operating-procedures/.

    Further detail in regard to the matters discussed in this Fact Sheet can be found on the Ministry of Health website at https://www.health.govt.nz/.

    Enrolment Explanation & Questions & Answers

    Our general practice is part of The Cause Collective, which is a Primary Health Organisation (PHO). We would like you to enroll with us.

    Enrolment means you plan to get most of your ongoing primary health care through our practice team and together we plan to meet your health needs.

    In addition, we will be working with our PHO and other health professional to improve the health of everyone enrolled with us and provide you & your community the opportunity to have your say about the services The Cause Collective practices provide.

    How does being enrolled with my family doctor benefit me?

    People who develop healthy partnerships with their practice teams generally enjoy better health care and have better health. By having up to date information, the practice will be better able to focus on helping you to stay in good health by coordinating healthcare services for you and your family. As you get to know the team here at Mangere Health Centre, you may feel more comfortable about asking questions and saying what your neds are. Developing a long-term relationship with your family doctor and practice team and other health professions will enable active early disease interventions rather than risking long term complications. When enrolled & funded with the practice, lower feeds will be charged.  

    How do I enroll?

    To enroll, you need to complete an Enrolment Form at the practice of your choice. Parents can enroll children under 16 years of age, but children over 16 years need to sign their own form. The practice will need to sight your NZ passport, or other password with NZ resident’s permit stamp or your birth certificate or your work or study 2-year visa.

    Health Information Privacy Statement

    It is compulsory for us to ask you to read and agree to Health & Information Privacy Statement before signing the enrolment form. Once you have read it, please tick the corresponding box on your enrolment form & sign it.

    I have my own GP, what do I need to do?

    Most people have a doctor they identify closely with. You may think of that doctor as “your” doctor. Enrolment is simple and if you are already an existing patient at this practice you will need to do very little to confirm that long-term relationship. Any member of the practice team will answer your questions and give you any further information you require.

    I don’t currently have a GP, what now?

    You may be welcomed to enroll with one of the doctors in this practice. If you do not expect to receive most of your health care services from us, you will need to remain as a casual patient.

    Can I change practices & enroll with another doctor?

    Yes, you are free to change practices. You will fill out a form similar to our enrolment form at the new practice and then, with your consent; your medical records will be transferred. Your name will be removed from our enrolment register and placed on your new GP’s register. You cannot be enrolled with two GP’s as there is only 1 funding stream available.

    Can I visit another healthcare provider for personal reasons or seek a second opinion but still remain your patient?

    Yes. You will see another healthcare provider as a casual patient, and you do not have to sign another enrolment form to be able to be seen. Please note that if you do sign another enrolment form you will be removed from our practices enrolment register and your personal patient medical records will be transferred. For this reason, it is important that you do not sign another enrolment form unless you now expect to receive most of your health care services from the other practice.

    What happens if I go to another General Practice?

    You can go to another practice or A & M centre as a visitor, but you may need to pay a higher fee for that visit. Instead to obtain free advice from a registered nurse when we are closed, you can call Healthline for free on 0800 611 116

    What happens if I am enrolled in a general practice but don’t see them very often?

    If you have not received services from your general practice in a three-year period, it is likely that the practice will contact you and ask if you wish to remain with the practice. The practice will ask you to resign an enrolment form meaning funding will continue and you will still be charged the lower funded fee when you do need to visit.

     

    PHO Contact Details – The Cause Collective

    Address:
    15 Earl Richardson Avenue, Wiri
    Auckland 2104, New Zealand

    Postal Address:
    PO Box 276002, Manukau
    Auckland 2241, New Zealand

    Phone: +64 9 869 2433
    Email: info@thecausecollective.org.nz
    Website: www.thecausecollective.org.nz

     

     

    Declaration: 

    • 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 agree to the practice sharing my health information with other health providers involved in my healthcare. 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 also agree to my information being used for practice quality/audit activities and to being included in the practice screening, recall and health programmes.

    • I understand that by enrolling with this practice I will be enrolled with the PHO - The Cause Collective. My name, address and other identification details will be included on both the practice and PHO enrolment 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 with the PHO and their contact details.

    • I agree to inform the practice of any change in my eligibility.

    • I understand that any accounts with an outstanding balance on my file at the end of the calendar month will attract a $3.00 statement fee.

  • Transfer of Records - In order to get the best care possible, I agree to the Practice obtaining my records from my previous Doctor. I also understand that I will be removed from their practice register.*
  • Consent

  • Date*
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  • Signed by:*
  • Should be Empty: