Enrolment

PERSONAL DETAILS
Which ethnic group(s) do you belong to? Select the ethnicities that apply to you.
RESIDENTIAL ADDRESS
POSTAL ADDRESS
CONTACT DETAILS
EMERGENCY CONTACT DETAILS
OTHER DETAILS

Note: If you are new to New Zealand, please select N/A, as we do not request medical notes from overseas.

(Accepted file types: .jpg,.jpeg,.tif,.tiff,.pdf)
Where signatory is not the enrolling person: An authority has the legal right to sign for another person if for some reason they are unable to consent on their own behalf (eg: parent of a child under 16 years of age).
IntelliMed