Enrol as a Patient

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.

• 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 Shirley Medical'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 Shirley Medical 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 Shirley Medical
• 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 Shirley Medical frequently, I may be dis-enrolled from Shirley Medical