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Enrolment Step 2

Fields marked with (*) are required.

Your Details

Health History

Do you have any health problems? (*)

Do any health problems run in your family?

Do you take any regular medications? (*)

Have you had any reactions to medications? (*)

What is your weight and height?

Do you smoke? (*)

Do you drink alcohol?

Immunisations

Are your childhood vaccinations up to date?

Female Screening (if relevant)

Are you female? (for screening questions related to females)

Are your mammograms up to date? (for ages 45-69)

Are your cervical smears up to date? (for ages 25-70)

Patient Portal Signup

Through the patient portal you can book appointments, view your blood results, view your medical history, and request repeat prescriptions securely online. The patient portal is free for all our enrolled patients. It is not available for casual patients or visitors.

Would you like to sign up to the patient portal? (*) Your username will be the email address you entered above.

Do you want to link your child(ren) to your portal account (under 15's only)?

Children age 15 or under can be enrolled to the portal under ONE parent's portal account. This allows you to book appointments for your child, view their test results and immunisation records etc.

Identity Verification

Please attach a copy of your current photo ID if you haven't already sent us one. (E.g. drivers license or passport)

Have you attached or sent through photo ID already? (*)

We send out newsletters for important updates. Our patients find it very useful. You can unsubscribe at any time.

Yes, I would like to sign up to the newsletter for important updates

Accounts Policy

For your convenience, our bank account details are on bottom of each invoice, on our website ellersliemedical.co.nz, and on Healthpoint. The reference number is your chart number noted on your invoice. We are committed to providing you the best possible care. However, in order to do this and maintain our fees at a reasonable level, please be aware of our policy with regard to payment of your account

Payment for Consultation and/or service is expected on the same day of the service. This may done at reception or once a credit history has been established, may be done through online banking within 24 hours at ASB 12-3060-0245732 Ellerslie Medical Centre. You can also pay with a credit card through our website.
Payments not made on the same day will incur an account fee of $5.00 for each calendar month of nonpayment. This fee will be reversed if payment is received within 14 days of the service.
Credit exceeding $100 Dollars is not permitted. Service may be refused if account remains unpaid unless there is a clinically urgent need.
All unpaid accounts 60 days overdue will be handed over to the debt collection agency and the costs associated with this will be added to the patient’s account for payment
Ellerslie Medical Centre reserves the right to vary this policy as it sees fit.

I acknowledge that I have read the above policy and agree to abide by these terms of payment. (*)

Please draw your signature (*)

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