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? Yes No

Is this appointment for a second opinion? * Yes No

2 Personal

Are you a New Zealand Citizen or Resident? * Yes No

Is this registration for a child? * Yes No

Address

Postal Address - same as Residential? * Yes No

Contact

Would you like txt message reminders? Yes No

Can messages be left on your Home or Mobile phone? * Yes No

Other

3 Health Providers

Were you referred by your Family Doctor? * Yes No

Are other health providers providing clinical services (optometrist, physio etc.) * Yes No

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: *

Cancer

Yes No

High blood pressure

Yes No

Heart attack or failure

Yes No

Angina or Chest pain

Yes No

Palpitations

Yes No

Bleeding tendency

Yes No

Rheumatic fever

Yes No

Blood clots / Thrombosis

Yes No

Clot location:

Legs Lungs Both

Stroke / TIA

Yes No

Blood disease

Yes No

Hepatitis

Yes No

Arthritis

Yes No

Kidney disease

Yes No

Diabetes

Yes No

Do you take Insulin:

Yes No

Emphysema / COPD

Yes No

Bronchitis

Yes No

Asthma / Short of breath

Yes No

Depression

Yes No

Epilepsy or Fainting

Yes No

Heart burn/Acid reflux

Yes No

Hiatus Hernia

Yes No

Thyroid disease

Yes No

Tuberculosis (TB)

Yes No

Glaucoma

Yes No

Do you suffer from or had treatment for any other serious illness or chronic pain: * Yes No

Females - Are you pregnant: Yes No Possibility

Do you smoke or vape: * Yes No

Do you drink beer, wine or spirits: * Yes No

Do you have any allergies, sensitivities or intolerances: * Yes No

Have you had any x-rays or scans related to your referral: * Yes No

Do you take anticoalgulant medication: * Yes No

Does your family have a history of Malignant Hyperthermia? *YesNo

Medications

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:

5 Additional Information

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

6 Payment

How will you be paying: * (tick and complete as many as apply)

Personally Parent or Guardian ACC Insurer Other

Personally

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.

Other

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

ACC

Accepted claim: Yes No

Note - ACC do not pay for personal expenses.

Insurer

Do you have prior approval for the treatment? Yes No Unsure

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

PATIENTS PLEASE NOTE THE FOLLOWING

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.

AGREEMENT

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: the Patient (aged 18 years or older)
a Parent, Guardian or person authorised to complete this form for the patient.

Patient Registration

1 Appointment

2 Personal

Address

Contact

Other

3 Health Providers

4 Medical

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

Medications

Previous Operations

5 Additional Information

6 Payment

Personally

Parent or Guardian

Other

ACC

Note - ACC do not pay for personal expenses.

Insurer

7 Attachments

8 Authorisation

PATIENTS PLEASE NOTE THE FOLLOWING

AGREEMENT

I agree to the above Terms & Conditions

Patient Registration

1 Appointment

2 Personal

Address

Contact

Other

3 Health Providers

4 Medical

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

Medications

Previous Operations

5 Additional Information

6 Payment

Personally

Parent or Guardian

Other

ACC

Note - ACC do not pay for personal expenses.

Insurer

7 Attachments

8 Authorisation

PATIENTS PLEASE NOTE THE FOLLOWING

AGREEMENT

I agree to the above Terms & Conditions

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