Plimmer Steps Medical Centre LP
PATIENT ENROLMENT FORM                           	

PATIENT DETAILS: (All fields marked with * must be completed)                         NHI #: 
Family Name:*
Previous/Maiden Name:	.
	First Name/s:*	 
	
Gender:*	 
M / F
Other	If other please state:	Date of Birth*
	Country of Birth:*	
	
Address:*	No./street*
	Postal address
(if different from physical address)	
	
	Suburb/City*

Email address:	

Phone number/s:	(home)
	(work)
	Smoking Status:	
Ex-Smoker     Current Smoker    Non-Smoker	
	(cell)
		Name of Employer:
Occupation:		
Emergency Contact:
	Name:

	Relationship to you:

	Contact number:

*I am eligible to enrol in Compass Health PHO. I choose to use this Practice as my regular and ongoing provider of general practice/GP/First Level primary health care services. I am eligible and entitled to enrol because I am residing permanently in New Zealand and I am a New Zealand Citizen (enter A)               OR meet one of the criteria laid out in the Eligibility Guide, enter the corresponding letter (enter B-K):  

-	I have read and agree to the terms in the 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.  
-	I confirm that if requested I can provide proof of my eligibility
-	I agree to inform the Practice of any changes in my eligibility. 
-	I understand that by enrolling with this Practice, I will be enrolled with the Primary health Organisation (PHO) this Practice belongs to and my name, address and other identification details will be included on both the Practice and the PHO Enrolment Register.
-	I understand that if I visit another 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 with the PHO, and their contact details. 
-	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 by informing the Practice. The survey provides important information that is used to improve health services.

*SIGNED: ___________________________ *DATE: _______________
or
*SIGNED AUTHORITY:  _________________*DATE: _______________
RELATIONSHIP TO PATIENT: _________________________________

Community Services Card/HUHC:	Y / N	Exp 	Transfer notes Previous GP	Y /N	Name:	
	#: 		Address:	
*Which ethnic group do you belong to?
Tick the space or spaces that apply to you

-	New Zealand European
-	Maori                                     
-	Samoan
-	Cook Island Maori
-	Tongan
-	Niuean 
-	Chinese
-	Indian
-	Other (such as DUTCH, JAPANESE, TOKELAUAN). Please state: 

Iwi: 

Do you permit us to contact you by text message for things such as appointment reminders and/or inform you of normal test results?     Yes                    No 

Medical Insurance: Yes/No
Medical Insurance Company:
Office use only:

Enrolling with Doctor: _________________
Evidence sighted:           y   /    n   /   na