I intend to use this practice as my regular and on-going provider of general
practice / GP / 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 the Practice, PHO and National
Enrolment Service Registers.
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 Use of Health Information Statement. The
information I have provided on the Enrolment Form will be used to determine eligibility to receive
publicly-funded services. Information may be compared with other government agencies, but only when
permitted under the Privacy Act.
I understand that the Practice participates in a national survey about people’s
health care experience and how their overall care is managed. Taking part is voluntary and all
responses will be anonymous. I can decline the survey or opt out the survey by informing the
Practice. The survey provides important information that is used to improve health services.
I agree to inform the practice of any changes in my contact details and entitlement
and/or eligibility to be enrolled.
New Zealand Citizens:
New Zealand Residents and Other Eligible Persons: