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.

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 First Name:

Emergency Contact Last Name:

Emergency Contact Relationship:

Emergency Contact Phone:

Smoking Status:

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

Yes

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?

Yes

Name of Previous Doctor/Practice:

Location of Previous Doctor/Practice:

Would you like to opt in to Manage My Health online personal health record? (click here for more info)

Yes

PERSONAL DETAILS

RESIDENTIAL ADDRESS

POSTAL ADDRESS

CONTACT DETAILS

MY DECLARATION OF ENTITLEMENT AND ELIGIBILITY