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\rodneysurg/History/.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



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


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.


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: (aged 18 years or older)

I agree to the above Terms & Conditions