Enrolment

Personal Details:

Title

First Name*

Last Name*

Gender*

Date of Birth*

Address:*

City*

Post Code

Contact Details:

Day Phone

Night Phone

Mobile Phone

Email*

Occupation

Do you want to receive text messages?

	Yes
	No

Emergency Contact

Name*

Relationship*

Contact Number*

Alternate Contact Number

Transfer of Records

For continuity of my care, I agree to the Practice obtaining a records transfer from my previous doctor. I also understand that I will be removed from the previous doctor�s practice register.*

	Yes
	No

I intend to use St Heliers Medical as my regular and ongoing provider of General Practice /GP/First Level primary healthcare services.*

I Understand

I understand that I will be required to complete and SIGN a more detailed form when I arrive at St Heliers Medical. I WILL BRING WITH ME IDENTIFICATION DOCUMENTS (eg Passport) for government funding purposes.*

I understand

PLEASE NOTE : COMPLETING THIS ONLINE FORM WILL HELP US BUT WE ARE NOT PERMITTED BY REGULATION TO CONFIRM YOUR ENROLMENT UNTIL A HARD-COPY DOCUMENT HAS BEEN SIGNED AND WE HAVE CONFIRMED YOUR IDENTIFICATION FOR GOVERNMENT FUNDING PURPOSES

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10 Turua Street, St Heliers
Phone +64 9 575 9491 (24h)
Emergency 111

Enrolment

UNICHEM MEDICAL PHARMACY

ST HELIERS MEDICAL

What does this mean for you?

10 Turua Street, St Heliers Phone +64 9 575 9491 (24h) Emergency 111

Enrolment

UNICHEM MEDICAL PHARMACY

ST HELIERS MEDICAL

What does this mean for you?

10 Turua Street, St Heliers
Phone +64 9 575 9491 (24h)
Emergency 111