Enrolment Form ~ The Village Medical Centre

PHONE: 03 441 4333

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ENROL AT

THE VILLAGE MEDICAL CENTRE

To be eligible for subsidised fees, please enrol with The Village Medical Centre prior to your visit. Our enrolment process can be completed online using the Enrolment Form below.

PLEASE NOTE that you will need to provide identification and/or supporting documents and upload them with this online form.

See below for a list of acceptable forms of identification:

New Zealand Citizens:

New Zealand Passport (No further documentation required);
OR
New Zealand Driver’s Licence AND one of the following:
~ Birth Certificate
~ Community Services Card

New Zealand Residents and Other Eligible Persons:

Passport AND one of the following:
~ NZ Visa (at least 2 years)
~ Residence Permit

Australian Citizens or Permanent Residents:

Australian passport, or other passport with Australian permanent resident/resident return visa AND
Evidence that New Zealand has been/will be your principal place of residence for at least two years (e.g. employment, house purchase). The two years are counted from your arrival date in New Zealand.

You will be prompted to upload any identification and supporting documents in Step 3 of our enrolment form. This could be a photo or a scanned file.

PATIENT ENROLMENT FORM

Kindly note in keeping with best practice nationwide, it is a requirement for patients 18 and over, to first consult with the practice nurse for clinical screening and a patient file review prior to booking an appointment with the doctor. This is essential for an effective transition in patient care from your previous medical centre to The Village Medical Centre.

"*" indicates required fields

Step 1 of 4

25%

Personal Information

First Names*

Surname*

Gender*

Ethnicity*

Current Address*

Street Address Town State / Province / Region Post Code Country

Postal Address*

Same as above

Use a different postal address

Enter Your Postal Address*

Email*

Cell Phone*

Date of Birth*

Place of Birth*

Name of Previous GP*

Address of Previous GP*

NHI Number

Are you a:*

Smoker

Non-Smoker

Ex-Smoker

Quit smoking date:

Insurance Details

Do you have health/medical insurance?*

Yes

No

What is the name of your insurance company?

What is your membership number?

Next of Kin

First Name*

Surname*

Contact Phone*

Enrolment in the Practice / Primary Health Organisation (PHO)

I intend to use THE VILLAGE MEDICAL CENTRE as my regular and ongoing provider of General Practice (GP) First Level primary health care services.

I am entitled to enrol because I am residing permanently in New Zealand and meet one of the following eligibility criteria:*

I AM A NEW ZEALAND CITIZEN. If yes, tick box and proceed to the next section, Enrolment Agreement.

I AM NOT A NEW ZEALAND CITIZEN. Please tick which eligibility criteria applies to you below:

I am entitled to enrol because I am residing permanently in New Zealand and meet one of the following elibibility criteria:*

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

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

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)

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

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

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

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

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

Do you wish us to register you for myindici, our online health and wellness portal?*

Yes

No

Enrolment Agreement

Enrolment Agreement 1*

I choose to enrol with THE VILLAGE MEDICAL CENTRE as my regular and ongoing provider of General Practice / GP / First Level primary health care services.

Payment Terms and Conditions Agreement*

I confirm that I have read and understood the Payment Terms and Conditions of THE VILLAGE MEDICAL CENTRE, and I hereby agree to be bound by the said Payment Terms and Conditions.

Enrolment Agreement 2*

I understand that by enrolling with THE VILLAGE MEDICAL CENTRE, I will be included in the enrolled population of Well South Primary Health Network, and my name, address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers.

Enrolment Agreement 3*

I understand that if I visit another health care provider, where I am not enrolled, I may be charged a higher fee.

Enrolment Agreement 4*

I have been given information about the benefits and implications of enrolment and the services which this practice, and the PHO, provides, along with the PHO’s name and contact details.

Enrolment Agreement 5*

I have read, and I 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 Privacy Act 2020 (or any Act which is passed in substitution thereof).

Enrolment Agreement 6*

I agree to inform the practice of any changes in my contact details and entitlement and/or eligibility to be enrolled.

Enrolment Agreement 7*

Payment & Debt Recovery – Payment is expected in full on the day of consultation. If you are unable to pay on the day, please discuss with reception and a fee may be added to your account.
I agree to be liable for any debt recovery costs I may incur for non-payment of my account.

Supporting Documentation

Please upload any supporting documentation such as the following identification;
New Zealand Citizens:
– New Zealand Passport, OR
– New Zealand Driver’s License, AND one of the following:
~ Birth Certificate
~ Community Services Card

New Zealand Residents and Other Eligible Persons:
– Passport, AND one of the following:
~ NZ Visa (at least 2 years)
~ Residence Permit

Australian Citizens or Permanent Residents:
– Australian passport, or other passport with Australian permanent resident/resident return visa, AND
– Evidence that New Zealand has been/will be your principal place of residence for at least two years (e.g. employment, house purchase). The two years are counted from your arrival date in New Zealand.

File

Max. file size: 2 MB.

Consent to Transfer Medical Records

Authorisation to transfer*

By checking this box, you are consenting for your personal medical records to be sent to: Dr Fiona Rorrison & Dr Laura Brown, The Village Medical Centre, 1092 Frankton Road, Queenstown.

Full Name*

Date*

Signature*

I have signed to say this information is true and correct. I acknowledge the signature I have drawn above is an accurate representation of my signature and constitutes an electronic signature for the purpose of the Electronic Transaction Act (2002) Disclaimer : Your practice will review the information you have supplied in this registration form and may request further supporting documentation to be completed if enrolment to the practice is sought.

Human Verification

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FIND US

The Village Medical Centre, Terrace Junction (BP Roundabout)
1092 Frankton Road, Queenstown

P 03 441 4333 E hello@villagemedicalcentre.co.nz

PRACTICE HOURS

Monday to Friday 8:00am to 5:00pm

In an emergency please dial 111

Or present to Southern Lakes District Hospital
20 Douglas Street, Frankton P 03 441 0015

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