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Millhouse Integrative Medical Centre : Partnering in Health and Healing

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Draft Rego Form

Practice Enrolment Form

Practice Name: Millhouse Integrative Medical Centre Phone Number: (09) 537 4980

Address: 128 Millhouse Drive, Northpark, Auckland 2013 Fax Number: (09) 537 5476

EDI Number millhsed

Register with us

Title

Given Name

Middle Name:

Family Name:

NHI Number

Date of Birth

Assigned Sex (at Birth)

Gender:

Place of Birth (Town/City):

Country of Birth:

Residential Address Street Number

Residential Address Street Name

Residential Address Suburb

Postcode

Residential Address City

Occupation

Community Services Card

Yes

No

High User Health Card

Yes

No

CS Card Number:

HUH Card Number:

CS Card Expiry Date

HUH Card Expiry Date

Home Phone:

Work Phone

Mobile Phone:

Email:

Do you agree to receive emails?

Yes

No

Emergency Contact Name

Relationship

Tel. contact

Do you agree to receive text messages

Yes

No

Do you smoke?

Yes

No (ex-smoker)

Never

Which Ethnic groups do you belong to?

New Zealand European

Maori

Samoan

Cook Island Maori

Tongan

Chinese

Indian

Other such as Dutch, Japanese, Tokelauan

Transfer of Records

Free Text

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

Previous Doctor's Name

Please state..........

Iwi affiliation (up to three)

Iwi 2

Iwi 3

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)

I am eligilbe to enrol becasuse

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

For all others

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