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  • 1298 Cameron Road, Greerton, 3112

    web: www.epichealth.nz

    EDI : EPICHEAL

     

    Email: admin@epichealth.nz

    Phone: 0800-374-254

  • Gender*

  • Date of Birth*
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  • Ethnicity Details - Which ethnic group(s) do you belong to? Tick the space or spaces which apply to you*

  • Smoking Status (applies to 15 years & over Only)*
  • Approximate Quit Date
     - -
  • Smoking is bad for your health. Would you like support to quit?*
  • If eligible for Breast Screening (females), do you consent to being enrolled into the recall system?*
  • Tick the box if you DO NOT want to receive communications by:
  • Enrollment Type*
  • 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:*
  • Browse Files
    Cancelof
  • Community Services Card
  • CSC Expiry date
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  • Enrollment

    I understand that by enrolling with Epic Health Medical Practice I will be enrolled with the Western Bay of Plenty PHO -Primary Health Organisation. 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 have read and I agree with the Health Information Privacy Statement in the accompanying PHO link https://wboppho.org.nz/privacy-policy/ 

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

    I understand that the practice is entitled to charge a fee for the health services it provides and that I agree to pay such costs according to the policy of the practice including any additional costs associated with the collection of overdue or unpaid accounts.

    I understand that Epic Health LTD may have staff that use practice approved AI tools to assist in providing healthcare services. All AI-assisted work is reviewed with human oversight to ensure its accuracy and appropriateness. AI will not be used for clinical decision-making or judgment. My health information will be used in accordance with legislative requirements and will not be shared with AI systems outside the practice without my consent. All data processed by AI tools will be handled securely and in compliance with data protection regulations. I will be informed about how AI tools are being used in my care and can ask questions or request more information at any time. I can also withdraw my consent at any point by notifying the practice.

  • 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.
  • Date *
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  • Signed by*
  • Today's Date
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  • Should be Empty: