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Enrol Now2018-03-15T16:26:33+00:00

Patient Enrolment Form

It is a requirement of the Ministry of Health that all eligible individuals who wish to be enrolled with Henderson Medical Centre, physically sign an enrolment form (or by their parent or guardian in the case of an individual being under 16 years of age).

To determine whether you qualify for publicly funded (free or subsidized) health care in New Zealand, please click here to access the Ministry of Health’s website explaining the eligibility criteria.

Please note: It is a Ministry of Health requirement that all new patients must provide proof of identity at the time of enrolment. This applies whether you are a NZ Citizen or not. Therefore, please include a photocopy of your passport or drivers licence when you post your signed enrolment form back to us. Please click here to see which documents are required in your situation.

To read more about the benefits and implications of enrolment, where personal information is sent and how it is used, please click here.


First Name(s):

Last Name:

Preferred Name:

Maiden Name:

Street Address:




Home Phone:

Work Phone:

Mobile Phone:

Email Address:

Please note: Your email address is required if you wish to book appointments, request prescriptions or view your test results online. Rest assured that we hold your email address in the strictest of confidence, in the same manner as all of your other personal information.

NZ Resident:

Please note: The definition of a NZ resident is that you are, or intend to be, living in NZ for at least 183 days in the next 12 months.

How Long in NZ:

If you are a new resident, we will need to see your passport or work permit to obtain an NHI number for you.

Date of Birth:

Country of Birth:

Which ethnic group(s) do you belong to? (you can choose up to 3 ethnicities):

Please select the doctor you would like to register with:

Do you have a Community Services Card?

If yes, please provide your card details.

CSC Card Number:

CSC Expiry Date:

Next of Kin:


NOK Address:

Contact Phone:

Your Employer:

Work Address:


Smoking status. Please select whichever applies to you:

How many years have you been a smoker?

Did you quit more or less than 12 months ago?

By clicking on the Submit button below, you are requesting an enrolment information pack to be posted to you by Henderson Medical Centre.