Enrolment

Online Enrolment Form

PERSONAL DETAILS

Date

Doctor* Dr Lakhminder Sandhu - MCNZ: 48174

Dr Dilawar Singh - MCNZ: 43838

Dr Patrick Yee - MCNZ: 71956

Dr Dasna Pallie - MCNZ: 46947

Given Name*

Middle Name(s)

Family Name *

Other Name

Other Given Name(s)

Other Family Name

Birth Date *

Place of Birth *

Country of Birth *

Occupation *

Gender *

Male

Female

Gender diverse (please state below)

USUAL RESIDENTIAL ADDRESS

House (or RAPID) Number and Street Name *

Suburb*

Town / City and Postcode*

POSTAL ADDRESS
(if different from above)

House Number and Street Name or PO Box Number

Suburb

Town / City and Postcode

CONTACT DETAILS

Primary Phone *

Secondary Phone

Your Email Address *

Do you want to receive the Txt Messages

Yes

EMERGENCY CONTACT / NOK

Given Name *

Family Name *

Relationship *

Mobile/ Phone *

ADDITIONAL INFORMATION

Community Services Card*

Yes

High User Health Card*

Yes

Smoking Status *

Smoker

Never Smoked

Ex-Smoker

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?

Yes

MY DECLARATION OF ENTITLEMENT AND ELIGIBILITY

YES, I wish to enrol with Hamilton Lake Clinic and use this practice as my regular and on-going provider of general practice / health care services. *

Yes

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

Yes

I am eligible to enrol because*:

a) I am a New Zealand citizen (If yes, tick box and proceed to I confirm that, if requested, I can provide proof of my eligibility below)

If you are not a New Zealand citizen, please tick which entitlement criteria applies to you (b–j) below*:

b) I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010)

c) 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

d) 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)

e) I am an interim visa holder who was eligible immediately before my interim visa started

f) 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

g) I am under 18 years and in the care and control of a parent/legal guardian/adopting parent who meets one criterion in clauses a–f above and control of the Chief Executive of the Ministry of Social Development

h) I am a NZ Aid Programme student studying in NZ and receiving Official Development Assistance funding (or their partner or child under 18 years old)

i) I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme

j) I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund

I confirm that I will provide proof of my eligibility. *

Yes

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.

Name of previous medical centre *

Transfer of Records*

I agree with [Hamilton Lake Clinic] obtaining my records from my previous doctor, which will mean I will be removed from their practice register.

Address of previous medical centre *

Authority *

Self-signing

On behalf of

Authority Full Name*

Relationship*

Contact Phone*

Basis of authority* (e.g. parent of a child under 16 years of age)

Comments

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

Digital Signature

I, the Applicant for this enrolment application, warrant the truthfulness of the information provided in this application. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the terms of conditions.

07 8390092, 02 26201600

Apply Online

Acceptable types of photo ID:

Acceptable types of proof of eligibility:

Blank Enrolment Form