Enrolment Form / Request for Transfer Form

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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