Pacific Island Community Trust

New Patient Enrolment Form

First Name

Last Name

Middle Name

Preferred Name (If different from First Name)

Title

Date of Birth

NHI Number

Ethnicity

Gender

Address

Suburb/ City

Postcode/Zip

Phone Number

Any additional information you like to provide about yourself

I hereby consent to the collection and use of my personal information as required for the purposes of providing healthcare services. I understand that my personal information will be stored securely and in accordance with relevant laws and regulations

Address

Message Sent.

Our services

Mobile Nursing Service (MNS)
Outpatient DNA & Advocacy (OPA)
Tobacco Control
Youth Mental Health (YMH)
Housing Advocate
Whanau Ora

Opening hours

Monday - Friday 8.30am - 4.30pm

Contact us

Phone: 07 577 1270
Email: pict_bop@pacificislandtrust.nz

26B Twelfth Avenue,
Tauranga South 3112

New Patient Enrolment Form

New Patient Enrolment Form

Our services

Opening hours

Contact us

Send us a message

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