ENDOSCOPY Auckland

ADMISSION FORM

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

PATIENT DETAILS

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


PRE PROCEDURE INFORMATION

Current weight (in kilograms)
KG
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
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

CURRENT MEDICATION

Insulin
Aspirin based products
Anticoagulants
Other Medicines - please list

OTHER INFORMATION

Allergies / Known Sensitivities
Infectious Diseases
Previous Abdominal Surgery / Procedures
Do you normally require antibiotics for dental procedures?
Other Surgery - 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