Enrolment Form Personal Details Name * First Name Last Name Other Names Known By (If applicable): NHI Number Date of Birth * MM DD YYYY Gender * Male Female Gender Diverse Place and Country of Birth * Ethnicity * Which Ethnic Group do you belong to? (Tick the spaces that apply to you) New Zealand European Māori Tongan Samoan Chinese Cook Islands Māori Niuean Indian Other Maternity Status * Pregnant Mother Preconception Not Applicable Physical Address Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Contact Details Phone * (###) ### #### Email * Primary Contact Name of Contact Person * First Name Last Name Relationship * Contact Phone Number * (###) ### #### Secondary Contact Name of Contact Person * First Name Last Name Relationship * Contact Phone Number * (###) ### #### Transfer of Records Would you like your records transfered? * In order to get the best care possible, I agree to the transfer of my records from my previous LMCor Kahu Taurima Provider. Yes No Not Applicable LMC or Kahu Taurima Provider Name? Address / Location Phone (###) ### #### Agreement My Agreement to the Enrolment Process I intend to use this provider as my regular and ongoing provider of Kahu Taurima services. I understand that by enrolling with this provider 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 Provider, PHO, and Arawhanui Databases. Link me/my family with resources from other agencies and foster changes that make organisations and social institutions more responsive to my needs. I have been given information about the benefits and implications of enrolment and the services this provider and PHO provides, and their contact details. Use of selected information e.g., photos/interviews/recordings to assist, support and inform progress of Tongan Health Society Integrated Outcomes Unit (verbal agreement will be sort prior to use). I agree to inform the practice of any changes in my eligibility. Health Information Privacy I agree to the practice sharing my health information with other health providers involved in my healthcare. 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 also agree to my information being used for Tongan Health Society Kahu Taurima quality/audit activities and to being included in the practice screening, recall and health programmes. I have been informed of the Health Information Privacy statement posters. I have read and agree to the Enrolment Process and the Health Information Privacy * Yes Thank you!
