CLP6-F2

ENROLMENT FORM / REQUEST FOR TRANSFER FORM

NAWTON MEDICAL CENTRE
64 Avalon Drive
Hamilton
Ph: 07 847 2383
Fax: 07 847 2385 / TE RAPA MEDICAL CENTRE
P O Box 10017
510 Te Rapa Straight
Hamilton
Ph: 07 849 6471
Fax: 07 849 6491 / NGAMIRO HEALTH CENTRE
P O Box 6
29A River Road
Ngaruawahia
Ph: 07 824 8393
Fax: 07 824 8227 / ENDERLEYPARK MEDICAL CENTRE
P O Box 14176
66 Tennyson Ave
Fairfield
Hamilton
Ph: 07 853 3370
Fax: 07 853 3373 / WAAHI HEALTH CENTRE
P O Box 148
Parry Street
(Parry Street Complex)
Huntly
Ph: 07 828 9256
Fax: 07 828 6631 / TEMPLEVIEW MEDICAL CENTRE
35 Cowley drive
Templeview
Hamilton
Ph: 07 847 1220
Fax: 07 847 1581

Where do you wish your paper records to be held? Please Tick one

Each person 16 years & over are to sign their own form

Family Name / Given Names / DOB / NHI / Male Female
(Please √ one)
Telephone No’s: / Home: / Work: / Mobile:

Note: your address must be where you live and not a PO Box or Private Bag

Street Address
Suburb: / City:
Phone: Work: Mobile:

What is your postal address, if different from where you live?

P. O. Box / Private Bag
Suburb / City

I understand that I will no longer be registered with my previous Doctor.

My Previous Doctors Name: / Clinic Name:Phone:
I authorize you to obtain my previous medical records:
Signature: Date:

Raukura Hauora O Tainui Obligations:

I have read and fully understand the information pamphlets on enrolling with this Primary Health organization.
I understand that:
  • When I enrol with this practice, the Primary Health Organization will use the information collected to build an enrolment register.
  • This register is then sent to the Minister of Health where my information will remain confidential.
  • The Ministry of Health need this information to:
-calculate the funding that is given to this Primary health Organization
-correct or update my details on the National Health Index (NHI Number)
-Monitor quality of care, health statistic’s and contractual obligations and to plan future health services.
  • My personal information will be used in Practice Activities such as Screening.
  • Raukura Hauora O Tainui may send my health information to other health professionals who are directly involved in my health care and medical treatment.
I declare I fully understand andthe information I have supplied on this form is correct:
Signature: …………………………………………………. Date of Enrolment: ………………………………

PLEASE TURN OVER TO FILL OUT BACK OF REGISTERED FORM

Next of kin:

Name / Relationship / Telephone

Help us to help you (please circle appropriate answers)

Are you a permanent resident of New Zealand? / YES / NO
If NO, Do you have a work permit? / YES / NO
Are you a Community Card Holder (Please show Receptionist) / YES / NO
Are you a High User Health Card Holder(Please show Receptionist) / YES / NO

Which Ethnic group do you belong to? Tick the box or boxes that apply to you

NZ Maori
Which Iwi do you belong to? / Iwi / Hapu
European not defined / Tongan / Chinese
NZ European/Pakeha / Niuean / Indian
NZ Maori / Tokelauan / Middle Eastern
PacificIsland / Fijian / Latin American
Samoan / Asian not defined / African
CookIsland Maori / South East Asian / Other

Training Participation:

Raukura Hauora O Tainui is a training facility for Doctors and Nurses. Your contribution/participation is greatly appreciated. If you do not wish to be seen by a trainee, please let us know. It is your right to decline/withdraw at any time from contributing/participating in these programs.

For office use only

National Health Index
(NHI) number
(If applicable)
HUHC number / Expiry day/month/year
Date
(f applicable)
CSC number / Expiry day/month/year
date

Date Issued: 01/01/01Date Reviewed: 01/01/10Version4

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