Patient Enrolment

Fields marked with * are compulsory

Personal Details

Contact Details

Enter postal address if different from above

Next of Kin

Employer Details

Put NA in employer details if not applicable

I am eligible to enrol because: *

Transfer of Medical Records

In order to get the best care possible, I agree to the practice obtaining my records from my previous doctor. I also understand that I will be removed from their practice register.

Current doctor and/or Practice name, and address (if known)

Documents *

A New Zealand Birth Certificate
AND a New Zealand Driver's License


A New Zealand Passport


An Overseas Passport
AND Visa

Services Card

Health Information

5. Do you have any family history of:

Which relation of yours?

How old were they at onset of disease?


 I consent to receiving health check reminders (e.g. immunisation and smear reminders), notifications and appointment reminders by Text messaging (SMS)

 I consent to medical centre sending me newsletter, surveys and information about services

 I wish to be texted an activation code for Manage My Health (patient portal) so that I can access my own notes, results, prescriptions etc.

My agreement to the enrolment process

NB. Parent or Caregiver to sign if you are under 16 years

Terms & Conditions

I intend to use this practice as my regular and on-going provider of general practice / GP / health care services.

I understand that by enrolling with Three Kings Accident and Medical I will be included in the enrolled population of National Hauora Coalition PHO, and my name address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers.

I understand that if I visit another health care 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 and the services this practice and PHO provides along with the PHO’s name and contact details.

I have read and I agree with the Use of Health Information Statement.  The information I have provided on the Enrolment Form will be used to determine eligibility to receive publicly-funded services. Information may be compared with other government agencies, but only when permitted under the Privacy Act.

I understand that the Practice participates in a national survey about people’s health care experience and how their overall care is managed. Taking part is voluntary and all responses will be anonymous. I can decline the survey or opt out of the survey by informing the Practice. The survey provides important information that is used to improve health services.

I agree to inform the practice of any changes in my contact details and entitlement and/or eligibility to be enrolled.

I have read and I agree with the Use of Health Information Statement.