Casual Patient Information Form

Complete this form if you wish to use our service as a casual patient i.e.

You’d like to use our services occasionally, but keep your enrolment with another GP provider
You’d like to use our services, but you aren’t eligible for subsidised GP care in NZ

* Required Fields

Personal information

Title *

First Name *

Middle Name
(Optional)

Last Name *

Gender *

Male
Female
Gender Diverse

Mobile Phone *

Date of Birth *

Day

Month

Year

Email Address *

Country of Birth *

Place of Birth *

Other Ethnicities
(Optional)

Street Address *

Suburb *

City *

Postcode *

Do you have a regular Family Doctor you usuall visit? *

Name of GP *

Practice Name
(Optional)

Address
(Optional)

Emergency Contact Name *

Emergency Contact Phone Number *

Community Service Card *

High User Card *

Terms
(Optional)

Terms, Conditions & Consents

I consent to receiving the Medical Treatment / Services that I am seeking today. I declare that the information given in this form is true and correct, and that I have not withheld any information likely to affect my application. By signing this Form, I am agreeing to the terms & conditions of release of health information. I authorize White Cross Healthcare to pass on parts of my information to the Ministry of Health and/or ACC. I also understand that it is my right under the Health Information Privacy Code to ask to see my personal or Health Information held by the doctor. I can ask for it to be corrected if it is wrong.

(If applicable) I authorise the treatment provider to lodge this claim for me, the collection and release of any information about me to the extent that this is needed to prevent future injuries, determine cover and/or assess my entitlement to compensation, rehabilitation assistance, medical treatment and/or the appropriate level of care and personal attention that I should receive, ACC to contact anyone who holds relevant information, including any external agencies or services providers (such as medical practitioners, specialists, New Zealand Police and Treatment Providers, IRD, WINZ, Assessment Agencies, employers and witnesses to the accident).

Your signature: *

Your Signature: