Enrol with us

Name *

First Name

Last Name

Gender *

Female

Male

Gender Diverse

High User Health Card *

Yes

No

Community Services Card *

Yes

No

Smoking Status *

Current

Never Smoked

Ex Smoker

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is the patient 16 or over? *

Yes

No

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

Yes

Not Applicable

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

Yes

No

Eligibility *

I intend to use Dynamic Family Doctors 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)

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

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 Alliance Health Plus 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 Dynamic Family Doctors 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. • 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 Dynamic Family Doctors frequently, I may be dis-enrolled from the Dynamic Family Doctors practice.

I accept the above enrolment agreement