ENDOSCOPY Auckland - ADMISSION FORM

PATIENT DETAILS

Title:

Gender:

Surname:

First Names:

Known As:

Personal Address:

Postal Address: (if different from personal address)

Phone numbers (Please provide at least one contact number)

Home Phone:

Mobile:

Business Phone:

Email:

Occupation:

Date of Birth:

Place of Birth:

NHI Number:

New Zealand Residency Are you a NZ resident (NZ citizen, hold a resident visa or permanent resident visa)? Yes No

Do you hold a 2 year work visa? (If Yes, attach copy of valid passport endorsed (stamped) with current work visa or work permit)

Yes No

NB: If you answered No to both of the above, you are not eligible for public funded healthcare in New Zealand - additional charges may apply.

Overseas patients ONLY (Non Residents)

Auckland Address:

Home Phone No:

Business Phone No:

(Please provide at least one overseas contact number)

Contact details

Contact Person (Full Name):

Relationship:

Address:

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

Home Phone:

Mobile Phone:

Business Phone:

Other details

Have you been a patient at Endoscopy Auckland before?

Yes No

General Practitioner & name of practice:

Referring Doctor & name of practice:

Endoscopist:

Date of Procedure:

Arrival Time:

Do you have Medical Insurance? (No travel insurance. Insurance companies with offices in NZ only)

Yes No

Medical Insurer:

Prior Approval No:

Other:

Southern Cross Insurance Membership No:

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

CURRENT MEDICATION

Insulin

Yes No

Aspirin based products

Yes No

Anticoagulants

Yes No

Other Medicines - please list

Yes No

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.

ADMISSION FORM

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

PATIENT DETAILS

Overseas patients ONLY (Non Residents)

Contact details

Other details

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 MEDICATION

OTHER INFORMATION