WeCare Health Online Enrolment Form

My agreement to the enrolment process
NB. Parent or Caregiver to sign if you are under 16 years
Please read and understand the Use of Health Information Statement and Benefits & Implications of Enrolment
- I intend to use this practice as my regular and on-going provider of general practice / GP / health care services.
- I understand that by enrolling with this Practice I will be included in the enrolled population of Pegasus Health Charitable Ltd PHO (Primary Health Organisation) and my name address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers.
- I understand that if I visit another health care provider where I am not enrolled I may be charged a higher fee.
- I have been given information about the benefits and implications of enrolment and the services this practice and PHO provides along with the PHO’s name and contact details.
- I have read and I agree with the Use of Health Information Statement. 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 understand that the Practice participates in a national survey about people’s health care experience and how their overall care is managed. Taking part is voluntary and all responses will be anonymous. I can decline the survey or opt out of the survey by informing the Practice. The survey provides important information that is used to improve health services.
- I agree to inform the practice of any changes in my contact details and entitlement and/or eligibility to be enrolled.
Signatory Details *

Clear
Date of signature *

Day Month Year
Date
Who signed this? *

Self-signing Authority
An authority has the legal right to sign for another person if for some reason they are unable to consent on their own behalf.

Authority Details: (where signatory is not the enrolling person)
Name of authority: *

First Name Last Name
Relationship: *
Phone Number *

Area Code Phone Number
Basis of authority (i.e. parent of a child under 16 years of age, parent or spouse with dementia, etc) *

*

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	Admin use only
For GP2GP transfer of	notes -
First name:	Wigram	edi wigramhl
Last name:	Health	NZMC 12345