I intend to use this practice as my regular and on-going provider of general practice / GP / health care services.
I understand that by enrolling with this practice I will be enrolled with the Primary Health Organisation (PHO) this practice belongs to, and my name, address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers.
I understand that if I visit another provider where I am not enrolled I may be charged a higher fee.
I have been given information about the benefits and implications of enrolment with the PHO, and their contact details.
I have read and I agree with the Use of Health Information Statement. The information I have provided on the Enrolment Form will be used to determine eligibility to receive publicly-funded services. Information may be compared with other government agencies, but only when permitted under the Privacy Act.
I understand that the Practice participates in a national survey about people’s health care experience and how their overall care is managed. Taking part is voluntary and all responses will be anonymous. I can decline the survey or opt out the survey by informing the Practice. The survey provides important information that is used to improve health services.
I agree to inform the practice of any changes in my contact details and entitlement and/or eligibility to be enrolled.