PATIENT ENROLMENT FORM – COURTENAY MEDICAL

PATIENT DETAILS: (All fields marked with * must be completed)

Email:*

Phone Number/s:* (h) (w) (mob)

Emergency Contact: Name: Relationship: Contact number:

Community Services Card / High User Card – Please hand to reception

Do you permit us to contact you by text message or email for things such as appointment reminders and/or inform you of normal test results?

(Please circle) Email: Yes or No Text: Yes or No

*I am eligible to enrol in Compass PHO. I choose to use this Practice as my regular and on-

going provider of general practice/GP/First Level primary health care services. I am eligible

and entitled to enrol because I am residing permanently in New Zealand and I am a New

Zealand Citizen OR meet one of the criteria laid out in the Eligibility Guide, with the

corresponding letter:

Please provide documentation to confirm your eligibility

Visa start date: __________ Visa expiry date: __________

I have read and 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 confirm that if requested I can provide proof of my eligibility

I agree to inform the Practice of any changes in my eligibility.

I understand that by enrolling with this Practice, I will be enrolled with the

Primary health Organisation (PHO) this Practice belongs to and my name, address

and other identification details will be included on both the Practice and the PHO

Enrolment Register.

I understand that if I visit another 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

with the PHO, and their contact details.

*SIGNED: ______________________________ *DATE: ___________________

or *SIGNED AUTHORITY: _________________ *DATE:___________________

RELATIONSHIP TO PATIENT: _________________________________________

An authority is the legal right to sign for another person if for some reason they are unable to consent on their own

behalf

*Which ethnic group do you belong to?

Tick the space or spaces that apply to you

New Zealand European

Maori

Samoan

Cook Island Maori

Tongan Niuean

Chinese

Indian Other (such as Dutch, Japanese,

Tokelauan) Please state:

Iwi:

*Patient Survey From time to time we may contact

you and ask for your feedback on your experience of care. This provides

important information which we use to improve health services.

Participation is voluntary and anonymous.

Yes I am happy to participate

No, I do not wish to participate Patient Survey contact details: As provided above Or alternative mobile or email:

Office use only:

Enrolling with doctor: _____________

Chart No. ______________

Evidence / ID sighted: y / n / na

Family Name:* Given Name/s:*

Title: Mr Mrs Ms Miss Mast Dr Preferred Name:

Date of Birth:* NHI:

Gender:* M F Other Country of Birth:*

If other gender please state: Place of Birth:*

Address:* Postal Address: (if different from physical address)

Courtenay Medical Level 5 Symes de Silva House

97-99 Courtenay Place, Wellington

Phone 04 801-5228 Fax 04 801-5229

Dr Dave Pickett NZMC: 15315 Dr Justine Lancaster NZMC: 17205

Dr Rebecca Rowe NZMC: 22271 Dr Alexander Lyudin NZMC: 59619

Medical Records Transfer Request Healthlink EDI: courteny

Date: / /

Dear Colleague:

Thank you for taking care of this patient in the past. This person, (and the family members listed

below), has asked to enrol with this practice, and has been accepted.

Our preferred method of transfer is GP2GP.

Previous Medical Centre Name and Address:

“I give consent to transfer my medical records, and those of my family”

Name Date of Birth Signature

Please note any person over the age of 16 is required to sign for their own medical records

Many Thanks

Reception

THE INFORMATION CONTAINED IN THIS FASCIMILE IS CONFIDENTIAL TO THE ADDRESSEE AND IS LEGALLY

PRIVILEGED. IF THE READER IS NOT THE INTENDED RECIPIENT, PLEASE NOTE THAT YOU MAY NOT USE ANY

MATERIAL IN THIS MESSAGE OR PASS IT ON TO OTHERS. IF YOU HAVE RECEIVED THIS MESSAGE IN ERROR

PLEASE NOTIFY US IMMEDIATELY. THANK YOU.

For office use only: Chart Number

Courtenay Medical

Credit Policy & Terms and Conditions of our Medical Centre

1. Payment for your consultation is required on the day of

consultation. Payment is accepted by Cash, Cheque, Eftpos, Visa or MasterCard and is

expected on the day.

An account fee of $8.00 will be charged for any account outstanding longer than

10 days

If you are unable to settle your account on the day of consultation, you must

advise reception of this prior to your consultation.

2. Appointments are 15 minutes – If you require longer than this, please

advise reception, charges will apply.

3. There is a minimum fee to see the nurse.

4. There is a charge for repeat prescriptions. These will only be issued for

regular medications and you have been reviewed for by the doctor within

the last 12 months. 24 Hours’ notice is required for this service.

5. We require 2 hours’ notice for any cancellation. Failing to attend an

appointment may result in a cancellation fee being charged.

6. Courtenay Medical uses the services of a debt collection agency. Any

unpaid accounts plus costs in recovering the unpaid account will be the

responsibility of the patient.

7. Please advise us of any changes to your contact details or eligibility status.

I acknowledge that I have read the above and agree with these terms and conditions

Signed:……………………………………… Patient Name:……………………………………….

All our fees are displayed on the notice board. If you require a copy please

ask at reception.

For office use only: Chart number