Pacific Health Plus Enrolment WAITLIST Form

Pacific Health Plus Enrolment Form

WAITLIST
Please fill out the form carefully to join our WAITLIST at Pacific Health Plus.

We will contact you once we are able to offer you a place of enrolment.

Until then, you will need to see your regular GP.
Practice Location
What Pacific Health Plus practice are you enrolling for?*

Porirua (4 Bedford Court, Cannons Creek)Kāpiti (9 Milne Drive, Paraparaumu)
Personal Details
Title*
e.g. Mr, Mrs, Ms
Given Name*
Other Given Name(s)
Family Name*
Preferred Name
Maiden Name or Other Names Used
Gender*

FemaleMaleGender Diverse (Please State)
Date of Birth*

DayMonthYear
DD-MM-YYYY
Place of Birth*
Country of Birth*

Usual Residential Address
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Postal Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Details
Email*
example@example.com
Mobile*
Home Phone
Work Phone

Emergency Contact
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship*
Emergency Contact Phone Number*
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Transfer of Records Authority

EDI: pacifihs | Dr Esela Natano | NZMC: 20978
In order to receive the best possible care, I agree to the Practice obtaining my records from my previous Doctor. I also understand I will be removed from their practice register.*

Yes - please request a transfer of my recordsN/A - not applicable (No GP in NZ. If your GP is overseas, you will need to obtain your own records)No - don't transfer my records (please note we cannot provide the best care without your records)
Previous Doctor and/or Practice Name*
Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Terms & Conditions of Credit*

I agree to be bound by the following terms and conditions of credit:
1. All accounts are payable on the day that the service is provided.

2. I shall pay or reimburse all costs and/or expenses incurred by Pacific Health Plus in recovering any amount overdue for payment by me.

3. An administration fee of $10.00 per month each month will be charged on all overdue accounts.

My agreement to the enrolment process

NB. Parent or Caregiver to sign if you are under 16 years
Enrolment Terms of Agreement*

I agree to the below terms of enrolment at Pacific Health Plus
I intend to use this practice as my regular and on-going provider of general practice & health care services.

I understand that by enrolling with Pacific Health Plus I will be included in the enrolled population of Tu Ora Primary Health Organisation, and my name address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers.

I agree for my relevant health information to be shared with other health professionals involved with my health care and well-being.

I understand that if I visit another health care 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 and the services this practice (www.phplus.co.nz) and Tu Ora PHO (www.tuora.org.nz).

I have read and I agree with the use of 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 1993.

I understand that the Practice participates in a national survey about people’s health care experience and how their overall care is managed. Taking part is voluntary and all responses will be anonymous. I can decline the survey or opt out of the survey 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.
Signatory Details*

Self-SigningAuthority (has the legal right to sign for another person if for some reason they are unable to consent on their own behalf)
Authority / Account Holder Details
Full Name*

First NameLast Name
Contact Phone Number*
Relationship*
Basis of Authority (e.g. parent of a child under 16 years of age)*
E-Signature*

Clear

Declaration
By selecting this box:*

I acknowledge that the information I have provided is accurate and complete.
Please verify that you are human*
Should be Empty:

Pacific Health Plus Enrolment Form

Practice Location

Personal Details

Usual Residential Address

Contact Details

Emergency Contact

Ethnicity

Transfer of Records Authority

My Declaration of Entitlement and Eligibility

My agreement to the enrolment process

Authority / Account Holder Details

Declaration