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.

Online Enrolment Form
PERSONAL DETAILS
USUAL RESIDENTIAL ADDRESS
POSTAL ADDRESS
(if different from above)
CONTACT DETAILS
EMERGENCY CONTACT / NOK
ADDITIONAL INFORMATION
MY DECLARATION OF ENTITLEMENT AND ELIGIBILITY
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