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Your Details

*Required Fields

Personal information

First Name

Last Name

Gender

Male
Female
Gender Diverse

Mobile Phone

Email Address

Date of Birth

Country of Birth

Place of Birth

Ethnicity

Other Ethnicities (Optional)

Unit/Apt Number (Optional)

Street Address

Suburb

City

Postcode

Is the patient 16 or over?

Authority Name

Authority Relationship

Authority Phone

Authority Basis

I give permission for my existing GP to transfer my patient notes

Yes
Not Applicable

Doctor or Practice Name

Address/Location

Do you want to participate in Patient Surveys? (Optional)

Medical information & eligibility

Eligibility

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

I am entitled to enrol because I am residing in New Zealand and meet one of the following eligibility criteria. The definition of residing permanently in NZ is that you have intend to be resident in New Zealand for at least 183 days in next 12 months. *

I am eligible to enrol because:

I am a New Zealand citizen (inc. Cook Islands, Niue or Tokelau)
I hold a resident visa or permanent resident visa (or a residence permanent if issued before December 2010)
I am an Australian citizen or Australian permanent resident AND able to show I have been in New Zealand or intend to stay in New Zealand for at least 2 consecutive years
I have a work visa/permit and can show that I am able to be in New Zealand for at least 2 years (previous permits included)
Other

I am an interim visa holder who was eligible immediately before my interim visa started
I am a refugee or protected person OR in the process of applying for, or appealing refugee or protection status, OR a victim or suspected victim of people trafficking
I am under 18 and in the care and control of a parent/legal guardian/adopting parent who meets one criterion listed above
I am 18 or 19 years old and can demonstrate that, on the 15th of April 2015, I was the dependant of an eligible work permit holder
I am a NZ Aid Programme student studying in NZ and receiving official Development Assistance funding (or their parent or child under 18 years old)
I am participating in the Ministry of Education Foreign Language Teaching Administration scheme
I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university
I am under the Commonwealth Scholarship and Fellowship fund

Proof of Eligibility - Your passport plus the relevant Visa if you are not a NZ Citizen

Upload a file Please upload an image or pdf document. Please upload a file 8MB or smaller. *

Upload another file... Please upload an image or pdf document. Please upload a file 8MB or smaller.

Enrolment Agreement

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 CityMed'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 CityMed 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 CityMed
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 CityMed frequently, I may be dis-enrolled from CityMed

I accept the above enrolment agreement

Your Signature:

You must provide a signature.

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