Durham Health

Apply to Enrol as a Patient

Please note that priority will be given to:

Patients who do not currently have a local GP
Patients who live or work in the Waimakariri area

 

 

 

Personal information
First Name *
Preferred Name
(Optional)
Last Name *
Gender *
Mobile Phone *
Email Address *
Date of Birth *
Occupation *
Country of Birth *
Place of Birth *
Ethnicity *
Other Ethnicities
(Optional)
Unit/Apt Number
(Optional)
Street Address *
Suburb *
City *
Postcode *
Emergency Contact Name *
Emergency Contact Relationship *
Emergency Contact Phone No. *
Is the patient 16 or over? *
Authority Name *
Authority Relationship *
Authority Phone *
Authority Basis *
Name of current GP/Practice Name *
GP/Practice Address/Location *
I agree to the Practice obtaining my records from my previous Doctor. I also understand that I will be removed from their practice register *
Community Services Card
Day / Month / Year of Expiry
(Optional)
Card Number
(Optional)
High Use Health Card
High Use Health Card Number
(Optional)
Smoking Status *
Would You Like Support To Quit? *
I am happy to be contacted by SMS *
I am happy for Durham Health to access health information from other providers (e.g. HealthOne) *
Medical information & eligibility
Eligibility Service
(Optional)
Eligibility

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

Eligibility Checkbox *
I am eligible to enrol because: *
Other Eligibility
Enrolment Agreement
Enrolment Agreement
(Optional)

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.

Enrolment Agreement
(Optional)

  • 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 Durham Health's PHO to be my PHO.

  • I have read and I agree with the Health Information Privacy Statement.

  • I have read and I agree with the Durham Health Terms of Trade

  • I agree to inform the practice of any changes in my eligibility.

  • I authorise Durham Health 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 at Durham Health

  • 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 Durham Health frequently, I may be dis-enrolled from Durham Health

I accept the above enrolment agreement *
Your Signature *
Your Signature *
Draw your signature using your mouse, finger, or other pointing device.
Proof of Eligibility
Proof of Eligibility Message
(Optional)

Your passport plus the relevant Visa if you are not a NZ Citizen.

Proof of Eligibility *
Proof of Eligibility *

    File types accepted: PDF, DOC, JPEG, PNG.
    Max file size: 8.3 MB

    Durham Health