Apply Online

Please complete this form to enroll with Hamilton Lake Clinic. Please make sure you fill in all required (*) fields

*To verify your identity, we require you to submit a copy of government-issued photo ID and proof of eligibility for public health funding. We may request additional documents and information where necessary depending on individual circumstances.

 

Acceptable types of photo ID:

  • New Zealand Passport
  • New Zealand Driver’s License

Acceptable types of proof of eligibility:

  • Birth Certificate
  • New Zealand Visa (must be more than 2 years/resident visa)
enrollment-form

Blank Enrolment Form

Please click the link below to download the blank Hamilton Lake Clinic Registration/Enrolment form for printing.

National Hauora Coalition
PERSONAL DETAILS
USUAL RESIDENTIAL ADDRESS
POSTAL ADDRESS
(if different from above)
CONTACT DETAILS
EMERGENCY CONTACT / NOK
ADDITIONAL INFORMATION
Smoking Brief Advice*
Did you know smoking is bad for your health? If you are a current smoker would you like brief advice to help you on the right track to quit smoking?
MY DECLARATION OF ENTITLEMENT AND ELIGIBILITY
I am entitled to enrol because I am residing permanently in New Zealand. *
The definition of residing permanently in NZ is that you intend to be resident in New Zealand for at least 183 days in the next 12 months
MY AGREEMENT TO THE ENROLMENT PROCESS

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


I understand that by enrolling with Hamilton Lake Clinic I will be included in the enrolled population of Hauraki 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 PHO provides along with the PHO’s name and contact details.

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

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

Before proceeding with this form, please note:

. Online enrollment will be reviewed by our administration staff, and the registration process will take approximately 1-3 working days to complete

∙ Completion of this online enrollment form is subject to review. If it does not meet the requirements, we will contact you for further information

∙ Medical notes transfer from previous clinic will take an average of 7 working days

∙ A double appointment (30 mins) is required for the first visit

For more details on Eligibility, click here