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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)

Street Address *

Suburb *

City *

Postcode *

Clinic Name *

Is the patient 16 or over? *

Yes No

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 *

I agree to receive Email / SMS comms and participate in surveys *

e.g. results, recalls, and health related matters.

Yes No

How did you hear about us?
(Optional)

Medical information & eligibility

Eligibility

I intend to use Tamaki Health 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 My situation is different to those listed above

If you do not match any of the situations listed above you may not be eligible to enrol with Tamaki Health. You may however be eligible for a limited range of services in certain situations please see the Ministry of Health website for more details.

The government strongly recommends that people in New Zealand who are not eligible for publicly funded health services hold comprehensive travel insurance, including health insurance.

Your Signature:

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