Enrolment

PERSONAL DETAILS

Title:

Given Name:

Middle Name(s):

Family Name:

Preferred Names:

Assigned Sex (at Birth):

Gender:

Date of Birth:

Country of Birth:

Place of Birth:

Preferred Language:

Which ethnic group(s) do you belong to? Select the ethnicities that apply to you.

Primary Ethnicity:

Secondary Ethnicity:

Tertiary Ethnicity:

Iwi 1:

Iwi 2:

Iwi 3:

RESIDENTIAL ADDRESS

Street Number and Name:

Suburb:

Town / City:

Postcode:

My residential and postal addresses are the same

POSTAL ADDRESS

Street Number and Name:

Suburb:

Town / City:

Postcode:

CONTACT DETAILS

Mobile Phone:

Work Phone:

Home Phone:

Email Address:

EMERGENCY CONTACT DETAILS

Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Contact Relationship:

Emergency Contact Phone:

OTHER DETAILS

Smoking Status:

If you currently smoke, would you like some help to quit?

Yes

Vaping Status:

Community Service Card Number:

Community Service Card Expiry:

High Use Health Card Number:

High Use Health Card Expiry:

Occupation:

Employer / School:

Employer Address:

Employer Suburb:

Employer City:

Employer Postcode:

Employer Phone:

Do you agree to this practice obtaining your medical records from your previous doctor?

Note: If you are new to New Zealand, please select N/A, as we do not request medical notes from overseas.

Yes

N/A

Name of Previous Doctor/Practice:

Location of Previous Doctor/Practice:

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