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

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
Auckland 1071, New Zealand
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part2

UNICHEM MEDICAL PHARMACY

Monday to Friday 8:30am-5:30pm
Phone: 09 575 5191
Fax: 09 575 5190
St-Heliers-Medical logo

ST HELIERS MEDICAL

Monday to Friday 8am-5:30pm
Phone. (09) 575 9491 (24hrs)
Fax. (09) 575 7031
part4

 

What does this mean for you?