Enrol with us for lower cost healthcare

Personal information

First Name *

Last Name *

Gender *

Male Female Gender Diverse

Date of Birth *

Day

Month

Year

Country of Birth *

Ethnicity *

Māori New Zealand European Samoan Cook Island Māori Tongan Niuean Chinese Indian Other

Mobile Phone *

Email Address *

Street Address *

Suburb *

City *

Postcode *

I agree to receive Email / SMS comms and participate in surveys *

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Are you currently a: *

Non-Smoker Smoker Vaper Ex-Smoker

Enrolment Agreement

My agreement to the enrolment process (NB Parent or caregiver to sign if you are under 16 years). I choose to enrol with this practice as my regular and ongoing provider of general practice / GP / First Level primary health care services.

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 have read and understood the requirements of enrolling with one PHO and choose Tamaki Health Group’s PHO to be my PHO.
I have read and I agree with the Health Information Privacy Statement.
I agree to inform the practice of any changes in my eligibility.
I authorise Tamaki Health Group to pass on parts of my health information to the Ministry Of Health.
I understand that relevant health information may be forwarded to other health professionals involved in my care.
I understand that my health information is accessible by all members of the primary care team and can be accessed at any Tamaki Health Group practice so that continuity of care is facilitated through a shared health record.
I understand that all members of the primary health care team have signed employment contracts containing confidentiality clauses or have signed confidentiality agreements and have completed privacy training so that my personal health information is kept confidential.
I understand that certain information in my daily clinical records can be made confidential to one GP only if required.
I also understand that it is my right under the Health Information Privacy Code 1994 to ask to see my personal or Health Information held by the doctor. I can ask for it to be corrected if it is wrong.
I understand that if I choose to see another doctor I will register at that practice as a Casual Patient, and if I see a GP outside of Tamaki Health Group practices frequently, I may be dis-enrolled from the Tamaki Health Group practices.
I agree to the transfer of patient notes from my existing GP where applicable.

I accept the above enrolment agreement

Communication opt-in *

Yes No

Your Signature:

Proof of Eligibility - e.g. Passport, Visa, Driving License, Birth Cert

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