Registration Form

Family Name

First Name

NHI

Date of birth

Address

Email Address

Telephone Number

Mobile Number

I confirm that I wish to request access to the following online services provided by Healthspace (please tick as appropriate):

Accessing my medical record (including details of medications / test results) as made available by the Practice.

Secure messaging with the Practice

Making an Appointment

Requesting Repeat Prescriptions

Participating in video consultation

Account payment

Accessing online resources

Please note that the online services made available to you by our Practice may vary from time to time and that past use by you of an online service and/or feature does not mean that it will continue to be available in the future.

In requesting access to the above services, I confirm that I understand and agree as follows (please tick all):

I have read and understood the information leaflet provided by the Practice.

I have read, understood and agree with the Patient Portal User Agreement on www.myindici.co.nz/termsandconditions.

I understand that if I share information with anyone else that I do so at my own risk.

I will contact the Practice immediately if I suspect that my account has been accessed by someone without my consent

If I see information in my account that does not relate to me, or is inaccurate or incorrect, I will log out of my account immediately and contact the Practice as soon as possible.

I will be responsible for the security of the information that I view or download.

Registration Preferences (please tick)

I wish to collect my registration details in person (with proof of identity)

I would like my registration details to be sent to me by post at the above address

Download Form as PDF

Registration Form

myIndici Portal

Registration Form

Download Form as PDF

Download myIndici App