Elstree Ave Family Doctors  New Patient 17 Elstree Avenue, Glen Innes ENROLMENT Auckland 1072  Re-Enrol Ph: 09 528 3323 Fax: 09 528 0445 FORM  Casual EDI: elstredr    Dr Donna Lahood Dr Lara Courtenay Dr Arushi Kaura Dr Mary Swan MBCHB, FRNZCGP MBCHB,DIP DERM,FRNZCGP MB, BS, FRNZCGP MBchB NZMC No. 15781 NZMC. 49868 NZMC No. 50967 NZMC No. 67296 NHI (Office use only) Name (Title) Given Name Other Given Name(s) Family Name Other Name(s) (e.g. maiden name) Please tick the name you prefer to be known as Birth Details Day / Month / Year of Birth Place of Birth Country of birth    Gender diverse (please state) Occupation Usual Residential Address House (or RAPID) Number and Street Name Suburb/Rural Location Town / City and Postcode Postal Address (if different from above) House Number and Street Name or PO Box Number Suburb/Rural Delivery Town / City and Postcode Contact Details Mobile Phone Home Phone Email Address Emergency Contact Name Relationship Mobile (or other) Phone In order to get the best care possible, I agree to the Practice obtaining my records from my previous Doctor. I also Transfer of understand that I will be removed from their practice register. Records    Yes, please request transfer of my records No transfer Not applicable Previous Doctor and/or Practice Name Address / Location Do you agree to receive text messages? Yes No New Zealand European Ethnicity Details Community Services Card Maori Which ethnic group(s) do Samoan you belong to? Tick the space or Cook Island Maori Tongan spaces which apply Niuean to you Day / Month / Year of Expiry Card Number Chinese Indian Yes No Other (such as Dutch, Japanese, High User Health Card Tokelauan). Please state Day / Month / Year of Expiry Card Number Yes No Never Do you Smoke? (ex-smoker) Primary Health Services Provider Enrolment Form Last Updated 2 November 2016
ENROLMENT FORM Elstree Ave Family Doctors 17 Elstree Avenue, Glen Innes Auckland 1072 Ph: 09 528 3323 Fax: 09 528 0445 EDI: elstredr New Patient  Re-Enrol  Casual  Dr Donna Lahood  MBCHB, FRNZCGP NZMC No. 15781 Dr Lara Courtenay  MBCHB,DIP DERM,FRNZCGP NZMC. 49868 Dr Arushi Kaura  MB, BS, FRNZCGP NZMC No. 50967 Dr Mary Swan MBchB NZMC No. 67296 NHI (Office use only) Name (Title) Given Name Other Given Name(s) Family Name Other Name(s) (e.g. maiden name) Please tick the name you prefer to be known as Birth Details Day / Month / Year of Birth Place of Birth Country of birth Gender    Occupation diverse (please state) Usual Residential Address House (or RAPID) Number and Street Name Suburb/Rural Location Town / City and Postcode Postal Address (if different from above) House Number and Street Name or PO Box Number Suburb/Rural Delivery Town / City and Postcode Contact Details Mobile Phone Home Phone Email Address Emergency Contact Name Relationship Mobile (or other) Phone Transfer of Records In order to get the best care possible, I agree to the Practice obtaining my records from my previous Doctor. I also understand that I will be removed from their practice register.  Yes, please request transfer of my records  No transfer  Not applicable Previous Doctor and/or Practice Name Address / Location Do you agree to receive text messages? Ethnicity Details Which ethnic group(s) do you belong to? Tick the space or spaces which apply to you New Zealand European Maori Samoan Cook Island Maori Tongan Niuean Chinese Indian Other (such as Dutch, Japanese, Tokelauan). Please state Community Services Card Yes No Day / Month / Year of Expiry Card Number High User Health Card Yes No Day / Month / Year of Expiry Card Number Do you Smoke? Yes No (ex-smoker) Never Primary Health Services Provider Enrolment Form Last Updated 2 November 2016
ProCare-Enrolment-Form_New_Updated-Nov-16.docx