New Brighton Health Centre

Enrol as a Patient

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
First Name *
Last Name *
Gender *
Mobile Phone *
Email Address *
Date of Birth *
Occupation
(Optional)
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 *
I give permission for my most recent GP to transfer my patient notes *
Current Doctor or Practice Name *
Address/Location *
Community Services Card *
Day / Month / Year of Expiry
(Optional)
Card Number
(Optional)
High Use Health Card *
Card Expiry Day / Month / Year
(Optional)
High Use Health Card Number
(Optional)
Smoking Status *
Would You Like Help To Stop Smoking? *
Medical information & eligibility
Eligibility Service
(Optional)
Eligibility

I intend to use New Brighton Health Centre 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)
Eligibility

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 New Brighton Health Centre's 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 New Brighton Health 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 at New Brighton Health Centre

  • 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 New Brighton Health Centre frequently, I may be dis-enrolled from New Brighton Health Centre

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

    New Brighton Health Centre