ENDOSCOPY Auckland

ADMISSION FORM

Fields marked in BOLD are mandatory. Fields in RED indicate missing or incorrect information.

PATIENT DETAILS

(if different from personal address)
Phone numbers (Please provide at least one contact number)

Overseas patients ONLY (Non Residents)

 (Please provide at least one overseas contact number)

Contact details

Please enter at least one personal (non-business) phone number below

Other details

Endoscopy Auckland will access Southern Cross’s Provider Portal to apply for prior approval. This may involve disclosure or collection of information to/from Southern Cross and you acknowledge we have your authority to do so.

I Acknowledge  

PRE PROCEDURE INFORMATION

(Please note that if you answer YES to any of the following, a short description is required e.g. Diabetes – Type II)
Current weight (in kilograms)
KG
Height (in centimeters)
CM
Any special diet requirements?
Do you require an interpreter? If so what language
Mobility aids required?
Heart Disease / Previous Endocarditis / Arrhythmias / Pacemaker
Heart Valve Disease / Replacement / Rheumatic Fever
CVA / Stroke
Decline in memory / mental function / Dementia
Liver Disease
Kidney Disease / Urinary Retention / Prostate Problems
Organ Transplant / Immunosuppression
Diabetes
Respiratory Disease
History Of Chemotherapy / Radiotherapy
Seizure Disorders
Hypertension (High Blood Pressure)
Clotting Disorder (Bleeding Tendencies)
Metalware in body
Metalware in body (surgery date)
Pregnant / Breastfeeding
Glaucoma
Other
Allergies / Known Sensitivities
Infectious Diseases
(current/previous e.g. Hepatitis, HIV)
Previous Abdominal Surgery / Procedures - please list
Do you normally require antibiotics for dental procedures?
Other Surgery - please list

CURRENT MEDICATION

Insulin
Aspirin based products
Anticoagulants
(Blood thinning medications - not including Aspirin)
Other Medicines - please list

Endoscopy Auckland is legally obliged to retain your records for 10 years. After 10 years, if a record has not been used, it can be disposed of in accordance with the Privacy Act. Would you like your records returned to you in the event of destruction?

Accounts are payable on completion of procedure. Should you default in any payment due to Endoscopy Auckland, ongoing unpaid accounts may incur collection fees, which will be passed on to the patient:

I Accept  

Please ensure that when you hit the Finish & Submit button that you receive an acknowledgement, otherwise the transmission is not successful.

NB: Fields in RED indicate missing or incorrect information. If information is missing, the form will automatically return you to the field that requires more information.