Enrol as a patient

When you and your family enrol with us, you pay significantly lower fees when you visit our clinics. The application form should take less than five minutes and there is no cost to enrol. All you need is your passport plus the relevant visa if you are not a New Zealand citizen.

Personal information

*Required Fields

First Name*

Last Name*

Gender*

MaleFemaleGender Diverse

Mobile Phone*

Email Address*

Date of Birth*

Country of Birth*

Place of Birth*

Ethnicity*

Other Ethnicities
(Optional)

Street Address*

Suburb*

City*

Postcode*

Clinic Name

Previous GP name

Is the patient 16 or over?*

YesNo

I give permission for my existing GP to transfer my patient notes*

YesNot Applicable

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

e.g. results, recalls, and health related matters.
YesNo

How did you hear about us?
(Optional)

Emergency Contact

Next to Kin

Contact Name*

Relationship*

Mobile Phone*

Medical information & eligibility

Eligibility

I intend to use Flatbush Medical Centre as my regular and ongoing provider of general practice / GP / First Level primary health care services.

I am entitled to enrol because I am residing in New Zealand and meet one of the following eligibility criteria. The definition of residing permanently in NZ is that you have intend to be resident in New Zealand for at least 183 days in next 12 months.*

I am eligible to enroll because:

I am a New Zealand citizen (inc. Cook Islands, Niue or Tokelau)I hold a resident visa or 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 yearsI have a work visa/permit and can show that I am able to be in New Zealand for at least 2 years (previous permits included)Other

I am an interim visa holder who was eligible immediately before my interim visa startedI 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 traffickingI am under 18 and in the care and control of a parent/legal guardian/adopting parent who meets one criterion listed aboveI am 18 or 19 years old and can demonstrate that, on the 15th of April 2015, I was the dependant of an eligible work permit holderI am a NZ Aid Programme student studying in NZ and receiving official Development Assistance funding (or their parent or child under 18 years old)I am participating in the Ministry of Education Foreign Language Teaching Administration schemeI am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand universityI am under the Commonwealth Scholarship and Fellowship fund

Proof of Eligibility -

If you are not NZ Citizen please provide need both ( Copy of Passport and relevant visa )

Proof of Eligibility - Your copy of passport if you are not a NZ Citizen

Proof of Eligibility - Your passport plus the relevant Visa if you are not a NZ Citizen

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 Flatbush Medical Centre 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 Flatbush Medical Centre 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 Flatbush Medical Centre 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 Flatbush Medical Centre practices frequently, I may be dis-enrolled from the Flatbush Medical Centre practices.

Your Signature:

Date

I accept the above enrolment agreement*