Patient Registration

Please enter this important information and submit prior to your appointment.
An asterick * means information must be provided, otherwise it is optional.
Your information will be managed in accordance with our Privacy Policy
If you have any questions regarding this form, please contact us

1 Appointment

Do you already have an appointment booked with us?

Is this appointment for a second opinion? *

2 Personal

Are you a New Zealand Citizen or Resident? *     
Is this registration for a child? *


Postal Address - same as Residential? *     


Would you like txt message reminders?     
Can messages be left on your Home or Mobile phone? *     


3 Health Providers

Were you referred by your Family Doctor? *  

Are other health providers providing clinical services (optometrist, physio etc.) *

4 Medical

In order for us to take the best possible care of you,
we need your medical history to be accurate and complete.

Please answer all questions.
Have you ever had or do you currently have any of the following: *
High blood pressure
Heart attack or failure
Angina or Chest pain
Bleeding tendency
Rheumatic fever
Blood clots / Thrombosis
Clot location:

Stroke / TIA
Blood disease
Kidney disease
Do you take Insulin:

Emphysema / COPD
Asthma / Short of breath
Epilepsy or Fainting
Heart burn/Acid reflux
Hiatus Hernia
Thyroid disease
Tuberculosis (TB)
Do you suffer from or had treatment for any other serious illness or chronic pain: *
Females - Are you pregnant:
Do you smoke or vape: *
Do you drink beer, wine or spirits: *
Do you have any allergies, sensitivities or intolerances: *
Have you had any x-rays or scans related to your referral: *
Do you take anticoalgulant medication: *
Does your family have a history of Malignant Hyperthermia? *


List ALL medications or substances you are currently taking: (include blood thinners, contraception pills and also self-medicating herbal, natural, chemical or over-counter remedies)

Previous Operations

List ALL operations you have had in the past:


C:\HostedSites\finnisHistoryblank.csv Is Not found Or Is Not accessible

6 Payment


If you are paying for yourself, you need to view and accept the Payment Terms & Conditions which are specified in the Authorisation section of this form.

Parent or Guardian

If a parent or guardian is paying, they need to view and accept the Payment Terms & Conditions which are specified in the Authorisation section of this form.


If you have arranged for an alternative method of payment please make sure the staff are aware of this prior to your consultation or treatment


Accepted claim:

Note - ACC do not pay for personal expenses.


Do you have prior approval for the treatment?

7 Attachments

Documents and/or Photos which maybe uploaded after completion of this form include:-
  • Referral Letter
  • Medical Certificate
  • Approval for Treatment (Workcover, ACC, Health Fund etc)
  • Medical reports or History
  • Condition related photos

I have documents to attach   

8 Authorisation



This practice is committed to providing quality healthcare for its patients. As a fundamental part of this commitment, principals and staff of the practice recognise the importance of ensuring that our patients are fully informed and involved in their healthcare.

Read More of the Privacy Policy


Mr Finnis and several other surgeons have a financial interest in the form of shares in Beyond Radiology. In no way does this effect any management decisions.



All patients will receive an Invoice for professional services, for which they are responsible for the payment of.  Other parties such as government agencies or health insurers may pay some or all of the amount invoiced, but it is still the patient's responsibility to ensure full payment is completed.

Invoices are itemised according to the fees charged by the specialist who is responsible for your care.  Other arrangements can be discussed with the professional who is providing the service.

ACC patients must provide correct details of the organisation accepting liability for payment of services including the claim number, claim approval, date of injury and employer name (if accredited by ACC) BEFORE treatment is undertaken.  If ACC decline to pay for consultations, you are responsible for payment.

You will be given your invoice after your consultation at which time settlement would be appreciated. Mastercard and VISA credit facilities are available.

The terms of the contract are settlement of all consultation accounts on the same day and surgical accounts within 30 days.

Please note, if your attendance is for a second opinion you should have all correspondence and investigations available from other clinicians.  There MAY be an increased charge for second opinions.


I have read the Privacy Policy and give permission for medical records to be kept about me and for correspondence to be sent to my referring doctor, general practitioners, other associated clinical providers and insurance company, where appropriate. 


I understand I am responsible for giving my specialist the correct ACC details and ensure my ACC claim has been accepted by ACC.  If ACC decline to pay for consultations, I understand I am responsible for the payment.


I undertake to pay all fees owing to my specialist, including, in the event that liability is denied, any outstanding accounts that have not been paid in full by my insurer.  I also understand that any outstanding monies requiring debt recovery will incur additional charges and I will also be responsible for any legal costs incurred.

I am: (aged 18 years or older)

I agree to the above Terms & Conditions