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Patient Portal

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Enrol

Personal Information

Title *

First Name *

Middle Name *

Last Name *

Gender *

Male

Female

Gender Diverse

Mobile Phone *

Home Phone *

Email *

Date of Birth *

Country of Birth *

Place of Birth *

Ethnicity *

Other Ethnicities

Occupation *

Street Address *

Suburb *

City *

Postcode *

Community Services Card *

Yes

Community Services Card Number *

Community Services Card Expiration *

High User Health Card *

Yes

High User Health Card Number *

High User Health Card Expiration *

Do you smoke? *

Yes

Need cessation support? *

Yes

Emergency Contact

Name *

Relationship *

Contact Number *

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.

Yes, please request transfer of my records

Casual only

Previous Clinic and / or Practice Name

Address / Location

My Declaration of entitlement and eligibility

I am entitled to enroll because I am residing permanently in New Zealand. The definition of residing permanently in NZ is that you intend to be resident in New Zealand for at least 183 days in the next 12 months

I am eligible to enroll because:

I am a New Zealand citizen (If yes, tick box and proceed to I confirm that, if requested, I can provide proof of my eligibility below)

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

I hold a resident visa or a 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 years

I 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)

I am an interim visa holder who was eligible immediately before my interim visa started

I 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 trafficking

I am under 18 years and in the care and control of a parent/legal guardian/adopting parent who meets one criterion in clauses a - f above OR in the control of the Chief Executive of the Ministry of Social Development

I am a NZ Aid Programme student studying in NZ and receiving Official Development Assistance funding (or their partner or child under 18 years old)

I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme

I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund

Proof of Eligibility

Your NZ passport / Birth Certificate or Citizenship (or any relevant visas and Passport if not a Citizen)

Valid files are JPG, PNG, GIF, PDF and WEBP. File size maximum is 2MB.

My agreement to the enrolment process

1.) I intend to use Te Puna Hauora as my regular and on-going provider of general practice / GP / healthcare services.

2.) I understand that by enrolling with Te Puna Hauora, I will be included in the enrolled population of the Primary Health Organisation Te Puna Hauora belongs to and my name address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers

3.) I understand that if I visit another healthcare provider where I am not enrolled, I may be charged a higher fee.

4.) I have been given information about the benefits and implications of enrolment and the services Te Puna Hauora and the PHO provides along with the PHO's name and contact details.

5.) I have read and I agree with the Use of Health Information 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.

6.) I understand that Te Puna Hauora participates in a national survey about people's healthcare 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 of the survey by informing Te Puna Hauora. The survey provides important information that is used to improve health services.

7.) I agree to inform Te Puna Hauora of any changes in my contact details and entitlement and / or eligibility to be enrolled.

I accept the above enrolment agreement

No SMS/Text Messaging

No Email

Signature: *