Personal Information

Emergency Contact

Transfer of Records

In order to get the best care possible, I agree to Te Puna Hauora obtaining my records from my previous Doctor. I also understand that I will be removed from the previous Doctors practice register.

My Declaration of entitlement and eligibility

If you are not a New Zealand citizen, please tick which eligibility criteria applies to you (b - j) below:

Proof of Eligibility

1. New Zealand Passport
2. Birth Certificate or Citizenship
3. Or any relevant visas and Passport if not a Citizen

My agreement to the enrolment process: