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NHI Number (if known)
Legal Name
Title
*
Given Name
*
Family Name
*
Other Given Name(s)
Birth Details
Date of Birth
Place of Birth
*
Country of Birth
*
Gender
Gender
Male
Female
Gender Diverse
Occupation
*
Community my contact
Usual Residential Address
House (or RAPID) Number and Street Name
*
Suburb/Rural Location
*
Town / City and Postcode
*
Postal Address (if different from above)
House (or RAPID) Number and Street Name
*
Suburb/Rural Location
*
Town / City and Postcode
*
Contact Details
Mobile Phone
Home Phone
Email Address
*
NOK Emergency Contact
Contact Name
Relationship
Mobile (or other) phone
House Number & Street Name or PO Box Number
Suburb/Rural Location
Town / City and Postcode
Text to remind
Do you permit us to contact you by text message for such things as appointment reminders and/or inform you of normal test results? (please circle)
Yes
No
Email- Do you permit us to contact you via email?
Yes
No
Do you agree to sign up to the patient portal?
Yes
No
Email- Do you permit us to contact you via email? (please circle
Yes
No
Do you agree to sign up to the patient portal? (please circle)
Yes
No
Community Services Card
Community Services Card
Yes
No
Day / Month / Year of Expiry
Card Number
Medical History
Usual Medication
*
Family History, Family History of Medical Conditions, Family History of Medical Conditions (e.g. cancer/heart/disease)
*
Allergies
*
Employer
Employer Name
*
Employer Phone
*
Employer Address
*
Ethnicity Details
Ethnicity
*
--- Select Choice ---
NZ European or Pakeha
Samoan
Cook Island Maori
Tongan
Niuean
Chinese
Indian
Other European
Other Asian
Other African
Other (please state)
Other Ethnicity
*
Patient Survey
Smoking Status
*
--- Select Choice ---
Smoker
Ex Smoker
Non Smoker
What is your preferred pharmacy?
*
Patient Survey Contact Details
As provided above
Alternative Mobile Phone
Alternative Email Address
I do not wish to participate in the Patient Survey
Alternative Mobile Phone
Alternative Email Address
Consent to share
I consent to share my Health information with other Health Providers involved in my care, Consent to share health information
Yes
No
I consent to share my records on Indici SEHR:
Yes
No
Transfer of Records
Transfer of Records
Yes, please request transfer of my records
No transfer
Not applicable
Previous GP
Address/Location
My declaration of entitlement and eligibility
I am entitled to enrol because I am residing permanently in New Zealand
I am entitled to enrol because I am residing permanently in New Zealand
AND I am eligible to enrol because
I am a New Zealand citizen
If you are not a New Zealand citizen, please tick which eligibility criteria applies to you (b–j) below:
I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010)
I am an Australian citizen or Australian permanent resident AND able to show I have been in New Zealand or intend to stay in New Zealand for at least 2 consecutive years
I have a current work visa/permit and can show that I am legally able to be in New Zealand for at least 2 years (previous visas / permits included)
I am an interim visa holder who was eligible immediately before my interim visa started
I am a refugee or protected person OR in the process of applying for, or appealing refugee or protection status, OR a victim or suspected victim of people trafficking
I am under 18 years and in the care and control of a parent/legal guardian/adopting parent who meets one criteria in clauses a–f above OR in the control of the Chief Executive of the Ministry of Social Development
I am a NZ Aid Programme student studying in NZ and receiving Official Development Assistance funding (or their partner or child under 18 years old)
I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme
I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund
Confirmation
I confirm that, if requested, I can provide proof of my eligibility
Signatory Details
Signature
Clear Signature
Day / Month / Year
Signatory Type
Self-Signing
Authoruty
Authority Details
Full Name
Relationship
Contact Phone
Legal basis of authority (e.g. parent of a child under 16 years of age)
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