Dr Patti Piper 13207
Dr Sarah English 40659
Dr Meg Thomson 44022
EDI - sunsetfd
Unit 3/317 Sunset Road, Sunnynook 0632
Phone: 09 478 2878
Fax: 09 478 3007
PATIENT ENROLMENT FORM
1.
Each person aged 16 years and over needs to sign their own form
Family Name
Given Name
Preferred Name
Date of Birth
Sex
Ethnicity
NHI (reception to
(see to Q4)
complete)
1.
2.
3.
4.
My preferred practitioner ……………………………………………………….. (Optional)
By signing this enrolment you are enrolling at Sunset Road Family Doctors not a specific Doctor, though you can let us
know you’re preferred Provider
2.
Contact Details
Street Address …………………………………………………………………….…. Suburb/Town …………….…………………………
City …………………………………………………….
Post code ……………………………
Phone (home) ……………………………………
Email …………………………………………………………………
Phone (mobile) ……………………………….
Phone (work) ……………………………
(are you happy to receive texts on this number? please circle one) yes
no
Is this your main contact number? please circle one yes no
Place of Birth ………………………………………
Occupation ………………………………………………………
Employer details …………………………………………………………………………………..
………………………………………………………………………………………………………….
3.
4.
Next of Kin/Emergency contact details
Name ……………………………………………………….
Street Address…………………………………………………………………………………………………
Phone (home) ……………………………….
Phone (mobile) ………………………………. Relationship ………………………..………………
Ethnicity
Which Ethnic group do you identify with? Please write code number in the ethnicity column above for each person being enrolled.
21
36
41
40
5.
Maori
Hapu/iwi……………….
Fijian
34 Niuean
South East Asian
Asian not defined
11
33
43
12
Community Services Card
Yes
Card Number ……………………………………………….
NZ European
Tongan
Indian
Other European
Yes
Card Number ………………………………………………
7.
Are you a New Zealand Citizen?
35
37
44
54
Tokelauan
Other Pacific Islands
Other Asian
Not stated
No
Start Date ……………………….… Expiry Date …………………………………
If No: Are you a permanent resident of NZ?
Work permit Status of at least 2 years
Yes
Yes
Yes
Smoking Status.
Past Smoker
Smoker
Cook Island Maori
Samoan
Chinese
Middle Eastern
No
Start Date …………………………. Expiry Date ……………………………….
High User Card
6.
32
31
42
51
No
No
No
If No: Passport and visa to be sighted
Never Smoked
ENROLMENT IN THE PRACTICE/PRIMARY HEALTH ORGANISATION (PHO)
I intend to use Sunset Road Family Doctors as my regular and ongoing provider of general practise / GP / First Level primary
health care services.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
I am a New Zealand citizen
I hold a resident visa or a permanent resident visa (or a residence permit issued before
December2010)
I am an Australian or Australian permanent resident AND able to show I have been in New Zealand or
intend to stay in New Zealand for a t 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 on clauses a-f above
I am 18 or 19 years old and can demonstrate that, on the 15 April 2011, I was the dependant of an
eligible work permit holder
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
I confirm that, if requested, I can provide proof of my eligibility
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes
MY AGREEMENT TO THE ENROLMENT PROCESS
I choose to enrol with this practice as my regular and ongoing provider of general practise / GP / First Level primary health
care services.
I understand that by enrolling with this practise I will be enrolled with the Primary Health Organisation (PHO) this practise
belongs to, and my name, address and other identification details will be included on both the Practise 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 I agree with the Health information Privacy Statement.
I agree to inform the practice of any changes in my eligibility.
Name ………………………………………………..
Signature …………………………………………
Date………………………………………
INFORMATION FOR GP 2 GP FILE TRANSFERS
Dr Patti Piper
13207
Dr Sarah English
Dr Meg Thomson 44022
40659
EDI - sunsetfd
REQUEST THE TRANSFER OF MY/OUR MEDICAL RECORDS
I understand that I will be removed from the register of my previous General Practice and I authorise the transfer of my records
(and/or my child/children under 16 years)
Yes
No
Family Name
1.
2.
3.
4.
Given Name
Date of Birth
NHI
Previous Surgery/GP Name ……………………………………………………………………………….
Address ……………………………………………………………..
Contact Details ……………………………………………………
Name …………………………………………………
Signature ……………………………………………
Date ………………………………….
Unit 3/317 Sunset Road, Sunnynook 0632
P: 09 478 2878
F: 09 478 3007 E: reception@sunsetrfd.co.nz