{"id":937,"date":"2021-12-17T07:06:06","date_gmt":"2021-12-17T07:06:06","guid":{"rendered":"https:\/\/villagemedicalcentre.co.nz\/?page_id=937"},"modified":"2024-03-11T21:47:34","modified_gmt":"2024-03-11T21:47:34","slug":"enrolment-form","status":"publish","type":"page","link":"https:\/\/villagemedicalcentre.co.nz\/enrolment-form\/","title":{"rendered":"Enrolment Form"},"content":{"rendered":"\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-2qdew-46315fb5b0efc19264f77971b276465c\">\n.avia-section.av-2qdew-46315fb5b0efc19264f77971b276465c{\nbackground-repeat:repeat;\nbackground-image:url(https:\/\/villagemedicalcentre.co.nz\/wp-content\/uploads\/2021\/10\/creampaper.png);\nbackground-position:0% 0%;\nbackground-attachment:scroll;\n}\n<\/style>\n<div id='av_section_1'  class='avia-section av-2qdew-46315fb5b0efc19264f77971b276465c main_color avia-section-large avia-no-border-styling  avia-builder-el-0  avia-builder-el-no-sibling  avia-bg-style-scroll container_wrap sidebar_right'  data-section-bg-repeat='repeat'><div class='container av-section-cont-open' ><main  role=\"main\" itemprop=\"mainContentOfPage\"  class='template-page content  av-content-small alpha units'><div class='post-entry post-entry-type-page post-entry-937'><div class='entry-content-wrapper clearfix'>\n<div  class='flex_column av-1jxsg-12197d7794a96128fec78e27841fb655 av_one_full  avia-builder-el-1  el_before_av_hr  avia-builder-el-first  first flex_column_div  '     ><section  class='av_textblock_section av-kvhfxhlc-f6c911e52fc7869e95aff65fdca25d24 '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><h2 style=\"text-align: center;\">ENROL AT<\/h2>\n<h3 style=\"text-align: center;\">THE VILLAGE MEDICAL CENTRE<\/h3>\n<\/div><\/section><br \/>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-9jula-6f9a5f8332a56e8570d7447b475b8eaf\">\n#top .hr.hr-invisible.av-9jula-6f9a5f8332a56e8570d7447b475b8eaf{\nheight:40px;\n}\n<\/style>\n<div  class='hr av-9jula-6f9a5f8332a56e8570d7447b475b8eaf hr-invisible  avia-builder-el-3  el_after_av_textblock  el_before_av_textblock '><span class='hr-inner '><span class=\"hr-inner-style\"><\/span><\/span><\/div><br \/>\n<section  class='av_textblock_section av-kvswyf7y-59da60388a60e823aec66d66f28c523d '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><h5>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.<\/h5>\n<p><strong>PLEASE NOTE that you will need to provide identification and\/or supporting documents and upload them with this online form.\u00a0<\/strong><\/p>\n<p>See below for a list of acceptable forms of identification:<\/p>\n<h5 style=\"text-align: left;\">New Zealand Citizens:<\/h5>\n<ul>\n<li style=\"text-align: left;\">New Zealand Passport (No further documentation required);<br \/>\nOR<\/li>\n<li style=\"text-align: left;\">New Zealand Driver&#8217;s Licence <strong>AND<\/strong> one of the following:<br \/>\n~ Birth Certificate<br \/>\n~ Community Services Card<\/li>\n<\/ul>\n<h5>New Zealand Residents and Other Eligible Persons:<\/h5>\n<ul>\n<li style=\"text-align: left;\">Passport <strong>AND<\/strong> one of the following:<br \/>\n~ NZ Visa (at least 2 years)<br \/>\n~ Residence Permit<\/li>\n<\/ul>\n<h5>Australian Citizens or Permanent Residents:<\/h5>\n<ul>\n<li style=\"text-align: left;\">Australian passport, or other passport with Australian permanent resident\/resident return visa <strong>AND<\/strong><\/li>\n<li style=\"text-align: left;\">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.<\/li>\n<\/ul>\n<p><strong>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.<\/strong><\/p>\n<\/div><\/section><br \/>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-brpla-dac1bbc8ff087978c481c2e408126375\">\n#top .hr.hr-invisible.av-brpla-dac1bbc8ff087978c481c2e408126375{\nheight:40px;\n}\n<\/style>\n<div  class='hr av-brpla-dac1bbc8ff087978c481c2e408126375 hr-invisible  avia-builder-el-5  el_after_av_textblock  el_before_av_textblock '><span class='hr-inner '><span class=\"hr-inner-style\"><\/span><\/span><\/div><br \/>\n<section  class='av_textblock_section av-kvsqjuce-9498939cf82bd469c1ddcac7c097479c '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><h2>PATIENT ENROLMENT FORM<\/h2>\n<\/div><\/section><br \/>\n<section  class='av_textblock_section av-ltnh13yz-0218d6092188b554c3298b1a8be1fcb6 '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><p>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.<\/p>\n<\/div><\/section><br \/>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-kvhgdb16-4f58317aad23a859e3f8eba54aa4e00b\">\n#top .hr.hr-invisible.av-kvhgdb16-4f58317aad23a859e3f8eba54aa4e00b{\nheight:40px;\n}\n<\/style>\n<div  class='hr av-kvhgdb16-4f58317aad23a859e3f8eba54aa4e00b hr-invisible  avia-builder-el-8  el_after_av_textblock  el_before_av_textblock '><span class='hr-inner '><span class=\"hr-inner-style\"><\/span><\/span><\/div><br \/>\n<section  class='av_textblock_section av-kvhfvk8e-78597ef231f2da735e1567b21bf04527 '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><script type=\"text\/javascript\">var 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class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_custom\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/wp-json\/wp\/v2\/pages\/937#gf_5' data-formid='5' novalidate>\n        <div id='gf_progressbar_wrapper_5' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>4<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_5_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_4\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_4\" ><h3 class=\"gsection_title\">Personal Information<\/h3><\/div><div id=\"field_5_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_10\" ><label class='gfield_label gform-field-label' for='input_5_10'>First Names<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_5_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_37\" ><label class='gfield_label gform-field-label' for='input_5_37'>Surname<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_5_37' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_38\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_38\" ><label class='gfield_label gform-field-label' for='input_5_38'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_5_38' class='large gfield_select'  aria-describedby=\"gfield_description_5_38\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Please select' selected='selected'>Please select<\/option><option value='Female' >Female<\/option><option value='Male' >Male<\/option><option value='Indeterminate' >Indeterminate<\/option><option value='Non-Binary' >Non-Binary<\/option><option value='Other Gender' >Other Gender<\/option><option value='Unspecified or Unknown' >Unspecified or Unknown<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_5_38'>\n<\/div><\/div><div id=\"field_5_39\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_39\" ><label class='gfield_label gform-field-label' for='input_5_39'>Ethnicity<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_39' id='input_5_39' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Please select' selected='selected'>Please select<\/option><option value='New Zealand European' >New Zealand European<\/option><option value='Maori' >Maori<\/option><option value='Samoan' >Samoan<\/option><option value='Tongan' >Tongan<\/option><option value='Fijian' >Fijian<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Niuean' >Niuean<\/option><option value='Tokelauan' >Tokelauan<\/option><option value='Other Pacific Islander' >Other Pacific Islander<\/option><option value='Chinese' >Chinese<\/option><option value='Indian' >Indian<\/option><option value='Southeast Asian' >Southeast Asian<\/option><option value='Other Asian' >Other Asian<\/option><option value='African' >African<\/option><option value='Middle Eastern' >Middle Eastern<\/option><option value='Other European' >Other European<\/option><option value='Other Ethnicity' >Other Ethnicity<\/option><option value='Don&#039;t Know' >Don&#039;t Know<\/option><\/select><\/div><\/div><fieldset id=\"field_5_16\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_16\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Current Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_5_16' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_16_1_container' >\n                                        <input type='text' name='input_16.1' id='input_5_16_1' value=''   placeholder='Street Address' aria-required='true'    \/>\n                                        <label for='input_5_16_1' id='input_5_16_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_16_3_container' >\n                                    <input type='text' name='input_16.3' id='input_5_16_3' value=''   placeholder='Town' aria-required='true'    \/>\n                                    <label for='input_5_16_3' id='input_5_16_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Town<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_16_4_container' >\n                                        <input type='text' name='input_16.4' id='input_5_16_4' value=''     placeholder='Region' aria-required='true'    \/>\n                                        <label for='input_5_16_4' id='input_5_16_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_16_5_container' >\n                                    <input type='text' name='input_16.5' id='input_5_16_5' value=''   placeholder='Post Code' aria-required='true'    \/>\n                                    <label for='input_5_16_5' id='input_5_16_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Post Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_5_16_6_container' >\n                                        <select name='input_16.6' id='input_5_16_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' selected='selected'>New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_5_16_6' id='input_5_16_6_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_5_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_66\" ><legend class='gfield_label gform-field-label' >Postal Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_66'>\n\t\t\t<div class='gchoice gchoice_5_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Same as above'  id='choice_5_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_66_0' id='label_5_66_0' class='gform-field-label gform-field-label--type-inline'>Same as above<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Use a different postal address'  id='choice_5_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_66_1' id='label_5_66_1' class='gform-field-label gform-field-label--type-inline'>Use a different postal address<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_67\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-two-thirds gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_67\" ><label class='gfield_label gform-field-label' for='input_5_67'>Enter Your Postal Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_5_67' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_70\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_70\" ><\/div><div id=\"field_5_13\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_13\" ><label class='gfield_label gform-field-label' for='input_5_13'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_13' id='input_5_13' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_41\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_41\" ><label class='gfield_label gform-field-label' for='input_5_41'>Cell Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_41' id='input_5_41' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_12\" ><label class='gfield_label gform-field-label' for='input_5_12'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_5_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_15\" ><label class='gfield_label gform-field-label' for='input_5_15'>Place of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_5_15' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_17\" ><label class='gfield_label gform-field-label' for='input_5_17'>Name of Previous GP<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_5_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_18\" ><label class='gfield_label gform-field-label' for='input_5_18'>Address of Previous GP<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_5_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_55\" ><label class='gfield_label gform-field-label' for='input_5_55'>NHI Number<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_5_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_5_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_19\" ><legend class='gfield_label gform-field-label' >Are you a:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_19'>\n\t\t\t<div class='gchoice gchoice_5_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Smoker'  id='choice_5_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_19_0' id='label_5_19_0' class='gform-field-label gform-field-label--type-inline'>Smoker<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Non-Smoker'  id='choice_5_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_19_1' id='label_5_19_1' class='gform-field-label gform-field-label--type-inline'>Non-Smoker<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_19_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Ex-Smoker'  id='choice_5_19_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_19_2' id='label_5_19_2' class='gform-field-label gform-field-label--type-inline'>Ex-Smoker<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_54\" ><label class='gfield_label gform-field-label' for='input_5_54'>Quit smoking date:<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_5_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_42\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_42\" ><h3 class=\"gsection_title\">Insurance Details<\/h3><\/div><fieldset id=\"field_5_58\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_58\" ><legend class='gfield_label gform-field-label' >Do you have health\/medical insurance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_58'>\n\t\t\t<div class='gchoice gchoice_5_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Yes'  id='choice_5_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_58_0' id='label_5_58_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='No'  id='choice_5_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_58_1' id='label_5_58_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_59\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_59\" ><label class='gfield_label gform-field-label' for='input_5_59'>What is the name of your insurance company?<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_5_59' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_60\" ><label class='gfield_label gform-field-label' for='input_5_60'>What is your membership number?<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_5_60' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_61\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_61\" ><\/div><div id=\"field_5_57\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_57\" ><h3 class=\"gsection_title\">Next of Kin<\/h3><\/div><div id=\"field_5_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_44\" ><label class='gfield_label gform-field-label' for='input_5_44'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_5_44' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_43\" ><label class='gfield_label gform-field-label' for='input_5_43'>Surname<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_5_43' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_45\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_45\" ><label class='gfield_label gform-field-label' for='input_5_45'>Contact Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_45' id='input_5_45' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_5_46' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_2' class='gform_page' data-js='page-field-id-46' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_9\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_9\" ><h3 class=\"gsection_title\">Enrolment in the Practice \/ Primary Health Organisation (PHO)<\/h3><\/div><div id=\"field_5_5\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_5\" >I intend to use THE VILLAGE MEDICAL CENTRE as my regular and ongoing provider of General Practice (GP) First Level primary health care services.<\/div><fieldset id=\"field_5_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_8\" ><legend class='gfield_label gform-field-label' >I am entitled to enrol because I am residing permanently in New Zealand and meet one of the following eligibility criteria:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_8'>\n\t\t\t<div class='gchoice gchoice_5_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='I AM A NEW ZEALAND CITIZEN.  If yes, tick box and proceed to the next section, Enrolment Agreement.'  id='choice_5_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_8_0' id='label_5_8_0' class='gform-field-label gform-field-label--type-inline'>I AM A NEW ZEALAND CITIZEN.  If yes, tick box and proceed to the next section, Enrolment Agreement.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='I AM &lt;strong&gt;NOT&lt;\/strong&gt; A NEW ZEALAND CITIZEN.  Please tick which eligibility criteria applies to you below:'  id='choice_5_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_8_1' id='label_5_8_1' class='gform-field-label gform-field-label--type-inline'>I AM <strong>NOT<\/strong> A NEW ZEALAND CITIZEN.  Please tick which eligibility criteria applies to you below:<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_3\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_3\" ><legend class='gfield_label gform-field-label' >I am entitled to enrol because I am residing permanently in New Zealand and meet one of the following elibibility criteria:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_3'>\n\t\t\t<div class='gchoice gchoice_5_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010)'  id='choice_5_3_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_3_0' id='label_5_3_0' class='gform-field-label gform-field-label--type-inline'>I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='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'  id='choice_5_3_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_3_1' id='label_5_3_1' class='gform-field-label gform-field-label--type-inline'>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<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_3_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='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)'  id='choice_5_3_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_3_2' id='label_5_3_2' class='gform-field-label gform-field-label--type-inline'>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)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_3_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='I am an interim visa holder who was eligible immediately before my interim visa started'  id='choice_5_3_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_3_3' id='label_5_3_3' class='gform-field-label gform-field-label--type-inline'>I am an interim visa holder who was eligible immediately before my interim visa started<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_3_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='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'  id='choice_5_3_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_3_4' id='label_5_3_4' class='gform-field-label gform-field-label--type-inline'>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<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_3_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='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\u2013f above OR in the control of the Chief Executive of the Ministry of Social Development'  id='choice_5_3_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_3_5' id='label_5_3_5' class='gform-field-label gform-field-label--type-inline'>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<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_3_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='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)'  id='choice_5_3_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_3_6' id='label_5_3_6' class='gform-field-label gform-field-label--type-inline'>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)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_3_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme'  id='choice_5_3_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_3_7' id='label_5_3_7' class='gform-field-label gform-field-label--type-inline'>I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_3_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund'  id='choice_5_3_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_3_8' id='label_5_3_8' class='gform-field-label gform-field-label--type-inline'>I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_62\" ><legend class='gfield_label gform-field-label' >Do you wish us to register you for myindici, our online health and wellness portal?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_62'>\n\t\t\t<div class='gchoice gchoice_5_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Yes'  id='choice_5_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_62_0' id='label_5_62_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='No'  id='choice_5_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_62_1' id='label_5_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_20\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_20\" ><h3 class=\"gsection_title\">Enrolment Agreement<\/h3><\/div><fieldset id=\"field_5_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_22\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Enrolment Agreement 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_22'><div class='gchoice gchoice_5_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='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.'  id='choice_5_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_22_1' id='label_5_22_1' class='gform-field-label gform-field-label--type-inline'>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.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_63\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_63\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Payment Terms and Conditions Agreement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_63'><div class='gchoice gchoice_5_63_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.1' type='checkbox'  value='I confirm that I have read and understood the  &lt;a href=&quot;https:\/\/villagemedicalcentre.co.nz\/payment-terms-and-conditions\/&quot; target=&quot;_blank&quot;&gt;Payment Terms and Conditions&lt;\/a&gt; of THE VILLAGE MEDICAL CENTRE, and I hereby agree to be bound by the said Payment Terms and Conditions.'  id='choice_5_63_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_63_1' id='label_5_63_1' class='gform-field-label gform-field-label--type-inline'>I confirm that I have read and understood the  <a href=\"https:\/\/villagemedicalcentre.co.nz\/payment-terms-and-conditions\/\" target=\"_blank\">Payment Terms and Conditions<\/a> of THE VILLAGE MEDICAL CENTRE, and I hereby agree to be bound by the said Payment Terms and Conditions.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_31\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_31\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Enrolment Agreement 2<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_31'><div class='gchoice gchoice_5_31_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.1' type='checkbox'  value='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.'  id='choice_5_31_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_31_1' id='label_5_31_1' class='gform-field-label gform-field-label--type-inline'>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.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_64\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_64\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Enrolment Agreement 3<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_64'><div class='gchoice gchoice_5_64_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.1' type='checkbox'  value='I understand that if I visit another health care provider, where I am not enrolled, I may be charged a higher fee.'  id='choice_5_64_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_64_1' id='label_5_64_1' class='gform-field-label gform-field-label--type-inline'>I understand that if I visit another health care provider, where I am not enrolled, I may be charged a higher fee.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_33\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Enrolment Agreement 4<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_33'><div class='gchoice gchoice_5_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='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\u2019s name and contact details.'  id='choice_5_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_1' id='label_5_33_1' class='gform-field-label gform-field-label--type-inline'>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\u2019s name and contact details.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_34\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Enrolment Agreement 5<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_34'><div class='gchoice gchoice_5_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='I have read, and I agree with the &lt;a href=&quot;https:\/\/villagemedicalcentre.co.nz\/health-information-privacy-statement\/&quot; target=&quot;_blank&quot;&gt;Use of Health Information Statement.&lt;\/a&gt;  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.'  id='choice_5_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_34_1' id='label_5_34_1' class='gform-field-label gform-field-label--type-inline'>I have read, and I agree with the <a href=\"https:\/\/villagemedicalcentre.co.nz\/health-information-privacy-statement\/\" target=\"_blank\">Use of Health Information Statement.<\/a>  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).<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_35\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_35\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Enrolment Agreement 6<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_35'><div class='gchoice gchoice_5_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='I agree to inform the practice of any changes in my contact details and entitlement and\/or eligibility to be enrolled.'  id='choice_5_35_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_35_1' id='label_5_35_1' class='gform-field-label gform-field-label--type-inline'>I agree to inform the practice of any changes in my contact details and entitlement and\/or eligibility to be enrolled.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_36\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_36\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Enrolment Agreement 7<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_36'><div class='gchoice gchoice_5_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='Payment &amp; Debt Recovery \u2013 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.  &lt;br&gt;I agree to be liable for any debt recovery costs I may incur for non-payment of my account.'  id='choice_5_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_36_1' id='label_5_36_1' class='gform-field-label gform-field-label--type-inline'>Payment &amp; Debt Recovery \u2013 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.  <br>I agree to be liable for any debt recovery costs I may incur for non-payment of my account.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_47' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"1\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"1\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_47' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"3\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"3\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_3' class='gform_page' data-js='page-field-id-47' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_23\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_23\" ><h3 class=\"gsection_title\">Supporting Documentation<\/h3><\/div><div id=\"field_5_51\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_51\" >Please upload any supporting documentation such as the following identification;<br>\n\n<strong>New Zealand Citizens:<\/strong><br>\n\u2013 New Zealand Passport, OR<br>\n\u2013 New Zealand Driver\u2019s License, AND one of the following:<br>\n~ Birth Certificate<br>\n~ Community Services Card<br><br>\n<strong>New Zealand Residents and Other Eligible Persons:<\/strong><br>\n\u2013 Passport, AND one of the following:<br>\n~ NZ Visa (at least 2 years)<br>\n~ Residence Permit<br><br>\n<strong>Australian Citizens or Permanent Residents:<\/strong><br>\n\u2013 Australian passport, or other passport with Australian permanent resident\/resident return visa, AND<br>\n\u2013 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.<\/div><div id=\"field_5_50\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_50\" ><label class='gfield_label gform-field-label' for='input_5_50'>File<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='2097152' \/><input name='input_50' id='input_5_50' type='file' class='large' aria-describedby=\"gfield_upload_rules_5_50\" onchange='javascript:gformValidateFileSize( this, 2097152 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_50'>Max. file size: 2 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_50'><\/div><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_49' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_49' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"4\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"4\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_4' class='gform_page' data-js='page-field-id-49' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_48\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_48\" ><h3 class=\"gsection_title\">Consent to Transfer Medical Records<\/h3><\/div><fieldset id=\"field_5_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_24\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Authorisation to transfer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_24'><div class='gchoice gchoice_5_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='By checking this box, you are consenting for your personal medical records to be sent to: Dr Fiona Rorrison &amp; Dr Laura Brown, The Village Medical Centre, 1092 Frankton Road, Queenstown.'  id='choice_5_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_1' id='label_5_24_1' class='gform-field-label gform-field-label--type-inline'>By checking this box, you are consenting for your personal medical records to be sent to: Dr Fiona Rorrison &amp; Dr Laura Brown, The Village Medical Centre, 1092 Frankton Road, Queenstown.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_29\" ><label class='gfield_label gform-field-label' for='input_5_29'>Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_5_29' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_28\" ><label class='gfield_label gform-field-label' for='input_5_28'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_5_28' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_52\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_52\" ><label class='gfield_label gform-field-label' for='input_5_52'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_5_52_Container' class='gfield_signature_container ginput_container' style='height:180px; width:650px; ' ><input type='hidden' class='gform_hidden' name='input_5_52_valid' id='input_5_52_valid' \/><canvas id='input_5_52' width='650' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_5_53\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_53\" >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)\n\nDisclaimer : 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.<\/div><div id=\"field_5_30\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_30\" ><label class='gfield_label gform-field-label' for='input_5_30'>Human Verification<\/label><div id='input_5_30' class='ginput_container ginput_recaptcha' data-sitekey='6LcSrgsdAAAAAJF237gsVBs3clH196LJa0qwld1q'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><\/div><\/div>\n        <div class='gform_page_footer 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