Fillable Enrolment Form (Word)

The signature section must be completed using a mouse or with a real life pen. If using a mouse you can do this easily by clicking in word on insert -> shapes -> lines -> freeform: scribble. Then draw your signature in the relevant sections. See here.

Here is our enrolment form – click on the icon – you may print, complete, sign, and scan it. If you’re not using a proper scanner or scanning cellphone app, you may take a photo which needs to be upright, cropped, clear and not grey. Please return it via email (via our contact form below), or fax (09-5256887). Alternatively you may post (Ellerslie Medical Centre, 41 Robert Street, Ellerslie, 1051) the completed and signed form to us or drop it off in person during working hours.

Please make sure you are eligible for subsidised care, you can read more about understanding fees and enrolment

The form includes important medical details, consent for transfer of old GP notes, and our debt policy. Please also include a copy of your passport, birth certificate and any relevant visas so we are able to access Ministry of Health funding for you.

We realise this is inconvenient for you, but please understand that we are required by Ministry of Health to follow this for every enrolment. Without proof of eligibility we cannot apply for the subsidised rates and we are not able to prescribe funded medication or order funded laboratory investigations.

Our practice belongs to the Procare PHO (primary health organisation).

To register to use the portal, please speak to our reception team.

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Eligibility Criteria for Subsidised Care


A person is fully eligible and entitled to enrol if he / she is residing in New Zealand and:


  • a) Is a New Zealand citizen OR
  • b) Holds a resident visa or a permanent resident visa (or a residence permit if issued before December 2010)




  • c) Is an Australian citizen or Australian permanent resident AND able to show that his/her total stay in New Zealand is or will be at least 2 years OR
  • d) Has a work visa/permit and is able to show that he/she is able to be in New Zealand for at least 2 years (previous permits included) OR
  • e) Is an interim visa holder who was eligible immediately before their interim visa started OR
  • f) Is a refugee or protected person OR is in the process of applying for, or appealing refugee or protection status, OR is a victim or suspected victim of people trafficking OR
  • g) Is under 18 years and in the care and control of a parent/legal guardian/adopting parent who meets one criterion in clauses a–f above OR
  • h) Is 18 or 19 years old and can demonstrate that, on 15 April 2011, he/she was the dependent child of an eligible work visa/permit holder (visa must still be valid) OR
  • i) Is a NZ Aid Programme student studying in New Zealand and receiving Official Development Assistance funding (or their partner or child under 18 years old) OR
  • j) Is participating in the Ministry of Education Foreign Language Teaching Assistantship scheme OR
  • k) Is a Commonwealth Scholarship holder studying in New Zealand and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund.