Apply to Enrol at Remuera Medical Centre

You will need the following to upload to us:

We will need your full name, date of birth, address and previous GP details.

If you wish to enrol multiple family members, you will need to complete these steps for each person separately.

Your details
First name:
Middle names:
Surname:
Address:
Postcode:
Date of birth:
Gender:
Email:
Mobile phone number:
Landline phone number:
Your occupation:
Ethnicity:
Town where you were born:
Country of birth:
Smoking status:

Your entitlement to healthcare funding
I am a...

Previous GP We will contact your previous GP to get your records transferred to us. Do you authorise the transfer of your medical records from your previous doctor? I understand that my name will be removed from the register of my previous general practice.
Surgery Name:
GP Name (if known):

Your emergency contacts
Name of Next-of-Kin:
Their contact number:
Their relationship to you:

Enrolment Consent
I wish to enrol/re-enrol with this general practice. I understand that: This provider is a member of a Primary Health Organisation (PHO) and I have been informed of the implications of enrolment with this PHO. I cannot enrol with more than one practice at the same time. This practice is funded on the basis of its enrolled register and information on this form will be sent to the Health Funding Organisation. I agree to the practice sharing my health information with other health providers involved in my healthcare. My information may be used for practice screening & recall programmes, and practice quality activities and audit. I have read this document and understand and agree that I am now an enrolled patient of this practice. I have been given and read the Health Information Privacy Statement

Please draw your signature here:

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