Patient Registration

1 Appointment

Do you already have an appointment with us? *

Please book an appointment before filling in this form. You can contact us for more information.

2 Personal Information

Are you a New Zealand Citizen or Resident? *     

Residential Address: *


Is this registration for a child? *
Billing Address - Same as Residential? *     

Phone Numbers:

Messages can be left on my Home or Mobile phone? *     
Any religious practices or cultural needs we should be aware of?

3 Referring Doctor Information

4 Insurance

Do you have private health insurance?

5 ACC Claim

Is this an ACC claim?
Accepted claim:

6 Medical History

Please answer all questions.
Have you ever had any of the following: *
High blood pressure
Heart trouble
Insertion of pacemaker
Kidney disease
Diabetes
Bleeding tendency
Rheumatic fever
Blood disease
Hepatitis
Lung disease
Blood clots / thrombosis
Epilepsy
Asthma
Females - Are you pregnant?
Have you been tested for HIV antigen: *
If so:
Do you smoke: *
Do you drink beer, wine or spirits? *
Are you allergic to any medicine or tapes: *
Have you ever been given cortisone tablets/injections: *
Have you had any x-rays or scans related to your referral: *
Have you suffered any serious illness in the past: *

7

No extra information required

8 Authorisation

PATIENTS PLEASE NOTE

All patients will receive an Invoice for professional services, for which they are responsible for the payment of. Other parties such as ACC or an insurer my 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.

We are an Affiliated Provider with Southern Cross. If you are a member please make sure you know your policy membership number on the day.

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.

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.

Costs associated with retrieval of overdue amounts will be payable by you.

Please note, if your attendance is for a second opinion you should have all correspondence and investigations available from other clinicians.


I agree that my medical information, including digital images, can be collected and stored electronically for the purpose of making sure that I receive appropriate care, treatment and for associated administrative, training or support tasks.

I agree that my medical information may be sent electronically to any of my treating medical practitioners.

I am aware that I am entitled to request access to and correction of my health information.

I agree to the Terms & Conditions