• v5.8 Capital Care - Include date of enrolment
    v5.7 Capital Care Specific Version
    v5.6 Remove NHI validation, update EBHC logo
    v5.5 WD not enrolling
    v5.4 EBHC enrolling again, update EBHC logo
    v5.3 Update EBHC criteria to be currently enrolled with Georgie at TMC only
    v5.2 Update EBHC to not enrolling
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  • WMG Enrolment Form for Capital Care Patients

  • This enrolment for is for patients enrolled at Capital Care Health Centre who would like to enrol at another WMG practice rather than be automatically transferred to Thorndon Medical Centre.

  • Which practice would you like to be your primary practice? Click on the logo below to select a practice:*

  • Practice Eligibility

  • Please complete the following:*

  • This enrolment form is only for patients enrolled at Capital Care Health Centre who would like to enrol at another WMG practice rather than be automatically transffered to Thorndon Medical Centre.

    As you are not currently enrolled with Capital Care, please see our standard enrolment form at https://www.wellingtonmedical.co.nz/enrolment-form

  • 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 eligibility for funding:

  • Do you reside permanently in New Zealand?*

  • 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?*

  • Eligibility

  • Please select the situation which applies to you:

  • 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 email us on capitalcare@wmg.co.nz so that we can assist you.

     

  • You have selected

    {EligibilityCriteria1}

    as your reason for eligibility.

    We will request a copy of the documentation to support this eligibility from the team at Capital Care Health Centre. If we need any further information then we will contact you directly to request this.

  • When would you like us to enrol you?*

  • If you enrol with us straight away, you will need to access your health care from {practice} once your enrolment is processed. If you select from 5 October, you can continue to be seen at Capital Care Health Centre in September and then at {practice} from 5 October onwards.

  • Your Personal Details

  • Name

  • Do you prefer to be addressed by a different name?*
  • Who would you like to be your GP?

  • 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?*

  • Please provide the following information for the person you would like us to associate your patient record with:

  • Date of Birth*
     - -
    2 digit day, 2 digit month, 4 digit year

  • Address

  • Do you have a different postal address?*

  • Phone numbers

  •  -
  •  -

  • Emergency Contact/Next of Kin

  •  -

  • Additional Information

  • Date of Birth*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Current Date
     / /
    2 digit day, 2 digit month, 4 digit year
  • Gender*
  • What was your physiological sex at birth?*
  • Which ethnic group do you belong to?*

  • Do you consent to receiving information from us via text message and email?*

  • Those with Community Services Cards and their descendants can receive additional funding for their health care.

  • Do you have a Community Services Card?*
  • Start Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Expiry Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Our Online Health Portal

  • {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?*

  • 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.

  • Previous GP or Medical Centre

  • Do you have a previous medical centre or GP?*
  • Do you authorise us to obtain your medical records from your previous medical centre or GP?*

  • Health Information

  • Do you have any known medical allergies?*
  • Have you or have you had a significant illness/surgery/medical condition?*

  • Family History

  • Please select any of the following that apply to you:

  • Smoking History

  • What is your current smoking status?*

  • 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.

  • 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?
  • What is your current vaping status?*

  • 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.

  • What type of vaping do you do?*

  • 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?
  • Brief Smoking Advice provided

  • Alcohol Consumption

  • 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?*
  • Date of your last tetanus injection:*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Do you know the date of your last measles injection?*
  • Date of your last measles injection:*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Do you have any Non-New Zealand Immunisation records?*
  • Would you like to upload these here or provide them to us later?*
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  • Cervical Screening

  • Do you want us to be your cervical screening organisation?*
  • Have you had a hysterectomy (surgical removal of the womb)*

  • Mammograms

  • Date of your last mammogram (if known):
     / /
    2 digit day, 2 digit month, 4 digit year
  • Were the results of this mammogram normal?
  • Do you give us permission to access your mammogram history and for future results to be sent to us?*

  • 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. 

  • 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. 

  • All patients over the age of 16 must sign for their own medical records.

  • Who is signing this form*
  • Date of Signature*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Should be Empty: