Enrolment

PERSONAL DETAILS

Student ID Number:

NHI Number (if known):

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

Other

Orchard Park

Bryant Hall

College Hall

Student Village

Silverdale Apartments

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:

Preferred Practice:

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:

Would you like to register for patient portal? (click here for more info)

Yes

Please sign below (clear signature)
(parent or guardian must sign if patient is under 16 years of age)

Authority:

Where signatory is not the enrolling person: An authority has the legal right to sign for another person if for some reason they are unable to consent on their own behalf (eg: parent of a child under 16 years of age).

New Zealand Citizens:

New Zealand Passport (No further documentation required); OR
New Zealand Driver's Licence, AND one of the following:
- Birth Certificate
- Community Services Card

New Zealand Residents and Other Eligible Persons: