Welcome to Beachhaven Medical

Thank you for choosing to enrol with us.

By filling in this form you are agreeing to enrol with this practice as your regular and on going provider of GP / primary health care services.

We will not ask you any personal health questions in this Enrolment Form, all details are stored securely and confidentially.

You will need to fill this out separately for each person/child you wish to enrol. You will need to have a photo of your passport, visa or birth certificate ready.

Dr Bhupendra Gurung     NZMC 32702

New Patient Registration

Patient Name*
Date of Birth*
Please let us know if you have a preference.
Address*
Please provide us with an email address unique to the patient registering today
Ethnicity*
Please select all that apply to you
Please State
Please State
Emergency Contact*
Would you like to enroll any children or dependents? (Under 15yrs)
Please enter Full name, Gender and Date of Birth
In order to get the best care possible, I agree to the practice obtaining my medical records from my previous doctor. I understand I will be removed from their practice register.
Community Services Card*
CSC Expiry
High User Health Card*
High User Health Card Expiry
Smoking Status (If over 15)
I confirm I am happy to receive communication from the practice via text or email
At our practice you can have access to your own secure patient portal to book appointments online and review results etc.

Declaration

I am entitled to enroll because I permanently reside in New Zealand*
I am a New Zealand citizen*
Please Select
No File Chosen
File uploads may not work on some mobile devices.
Please take or upload a photo of your passport or birth certificate
Are you Signing this yourself or on behalf of someone else?*
An authority has the legal right to sign for another person if they are unable to consent on their own behalf.
Please enter full name, Contact phone and basis of authority.
Use your mouse or finger to draw your signature above

I understand that by enrolling with this practice, I will be enrolled with the Primary Health Organisation (PHO) this­ practice belongs to. My name, address and other identification details will be included on both the Practice and ­the PHO Enrolment Register. ­

I understand that if I visit another 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 with the PHO, and their contact ­details. ­

I understand that all accounts are payable on the day of consultation. If this is not possible, I will make arrangements with reception directly as to when and how my account will be paid.

Administration fees will be added to overdue accounts.

I understand that after my paper notes have been entered into the system, my patient file will be returned to me.

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