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\rodneysurg/History/.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

PRIVACY

We are committed to providing quality healthcare for our patients. As a fundamental part of this committment, we recognise the importance of ensuring that our patients are fully informed and involved in their healthcare.

Click here for our Privacy Policy

PAYMENT

All patients will receive an Invoice for professional services and materials, 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 materials or services used and the fees charged by the specialist, who is responsibile for your care. Other arrangements can be discussed with the professional who is providing the service.

If consultation or treatment is related to an injury, patients must provide correct details of the organisation accepting liability for payment of services including the claim number, date of injury and employer name 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.

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.

The terms of the contract are; settlement of all consulation accounts on the same day and surgical accounts within 30 days of the invoice date.

If full payment is not received within this time and debt collection is required, we will charge you any costs we or our agents incur in recovering money you owe us and we may disclose information about your non-payment to a credit reporting agency.

AGREEMENT

I understand that any costs given to me before surgery are estimates only and that I am responsible for any outstanding balance if my procedure is not fully covered by insurance, ACC or another contract. I accept that in the event that my hospital account is not paid, Rodney Surgical Centre reserves the right to add all costs of collection to this account. I accept that if my planned surgery is cancelled RSC is not liable for any loss to my income.

I understand that the surgeon, anaesthetist and any other doctor or health professional using the Rodney Surgical Centre facilities for operations, consultations or otherwise in relation to my care and treatment, and in relation to my account payment, are independent contractors and are not employees, agents or members of Rodney Surgical Centre. Accordingly, I accept that Rodney Surgical Centre is not liable for their actions or omissions.

I understand that from time to time, other clinical personnel may be required to be in the theatre during my procedure.

I give permission to Rodney Surgical Centre to collect and store information and clinical photos about me and my treatment with the understanding that any information will only be used for its intended purposes; that it will be kept securely in my medical file and/or computer system; shared only with health professionals involved in my care; government bodies will only be provided with information to which they are legally entitled. I have the right to check the accuracy of any information and to request corrections if necessary.

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.