• Patient Enrolment Form

    Patient Enrolment Form


  • EDI/GP2GP:wauckmsc | Dr Satya Shanbhag | NZMC: 43421
    Email:reception@wamsc.co.nz | Contact 09 242 3358 
    149, Henderson Valley Road, Henderson - Auckland -0612

  • The application form should take less than five minutes and there is no cost to enrol. All you need is your passport plus the relevant visa if you are not a New Zealand citizen.

    We have simplified the enrolment process to make it hassle-free for you. We require patients to complete the registration/patient form before their first appointment can be scheduled.

    Please be advised, the enrolment process takes 24 to 48 hours from the time we receive the full paper work.

    • Patient Details 
    • Contact Details 
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    • Emergency Contact 
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    • Transfer of Records 
    • Occupation 
    • Ethnicity details 
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    • My declaration of entitlement and eligibility 
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    • Proof of Identity 
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    • My Agreement To The Enrolment Process With West Auckland Medical & Surgical Centre 

    • NB. Parent or Caregiver to sign if you are under 16 years

      • I intend to use this practice as my regular and on-going provider of general practice / GP / health care services.
      • I understand that by enrolling with the West Auckland Medical & Surgical Centre, I will be included in the enrolled population of National Hauora Coalition PHO, and my name address and other identification details will be included on the Practice, PHO, and National Enrolment Service Registers.
      • 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, and PHO provides along with the PHO’s name and contact details.
      • I have read and I agree with 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 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.

    • I confirm that my action here confirms it is my signature and is binding.

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