Please complete all sections and submit. (Any questions should be directed to our hospital administrator on 096238525)

Private and Confidential

NHI Number If Known

Please answer the following questions by ticking the Yes or No box as appropriate


Do you have any allergies to drugs/medicine, latex, plasters, food?
Have you been told of any problems with your airway under anaesthesia?
Have you or your family had any problems with anaesthetics?
Do you have any problems opening your mouth?
Have you had/do you have
Heart conditions: Palpitations / chest pain / angina / heart murmur / Heart attack / previous Rheumatic fever / congestive heart failure
Lung Conditions: Asthma / shortness of breath / Wheeziness / Bronchitis / Emphysema / Persistent Cough
Blood Clots: Deep vein thrombosis (DVT) / Pulmonary Embolus (PE)
Infectious Diseases: Tuberculosis / Hepatitis / ESBL / VRE / MRSA / HIV / COVID
Pacemaker / ICD / Artificial Heart Valve / Cardiac stent
High Blood Pressure: controlled by medication
Heartburn / Indigestion
Diabetes Type I insulin dependant
Diabetes Type II Medicated
Kidney disease
Urinary or Prostate Conditions
Rheumatoid Arthritis
Obstructive sleep Apnoea
Using CPAP Mask
Stroke/Seizures/Blackouts or Fainting/TIA
Decline in memory / mental function / Dementia
Blood or Bleeding Disorder
Liver Disease : Jaundice/Hepatitis
Thyroid Condition
Do you suffer from any other condition, not covered elsewhere that you feel we should know about?
Any Condition affecting your Movement/Mobility
Motion Sickness: Car/Sea
Are you Pregnant/Breastfeeding?
Do you Smoke/Vape?
Do you drink Alcohol?
Recreation Drugs
What Physical activities do you partake in regularly
  Gym Work
I can climb stairs without getting short of breath
One flight    Two flights    More
My Activity is restricted by
  Shortness of Breath
  Chest Pain
  Joint Pain
Do you have
  Partial Plate
  Capped Teeth
  Loose Teeth

Previous Hospital Admissions and Surgeries (please list)   None (please indicate where and when admitted)
Current Medications including herbal medication   None


Phone Number
New Zealand Resident
Do you require an interpreter?
Contact Phone Number

Admission details

Dietary Requirements
Previous Hospital Admissions
Have you been a patient in this Hospital before?

Overseas Patients

Overseas patients are required to make payment on admission based on the estimated total cost of the hospital stay.

If you have medical insurance you will need to obtain prior approval from the insurance company before admission and supply your letter of authority from the insurance company to Endoscopy Auckland prior to admission. If you have any questions please contact the Hospital Administrator on (09) 6238525.

  I acknowledge and will comply with this

Financial Details

Payment of all monies due to Endoscopy Auckland are required on discharge or within 7 days of receiving invoice. Endoscopy Auckland may notify a debt collection agency should an account remain unpaid after 1 month. Any collection fees incurred by the hospital will be passed onto the patient.

If Southern Cross medical insurance some procedures are covered under an Affliated Provider agreement in which case Endoscopy Auckland will apply for prior approval and claim payment.

Name of Insurance Company
Type of Policy and Number
Prior Approval Number
Please bring your Prior Approval letter with you on admission

Non-insured Patients

Uninsured patients: If you are not insured you will be required to pay for your procedure on the day of discharge.

ACC claims: If your medical procedure is being paid or part-paid by ACC, ACC will pay Endoscopy Auckland directly for hospital and specialist costs. Any ACC Letter of Approval must be received by the hospital prior to admission. ACC does NOT ALWAYS COVER FULL COSTS of hospitalisation. The hospital Administrator can discuss this further if required. They can be contacted on (09) 6238525.

Payment Details - how you will be paying
Credit Card
EFT-POS (Bank limits may apply)
Personal Information
I consent to Endoscopy Auckland sharing relevant information as required with third parties such as medical insurers, medical consultants and the ACC, and debit collection agencies.
Personal Property
I understand and agree that Endoscopy Auckland is not and will not be responsible for the loss of or damage to any personal property (including jewellery, watches, rings, glasses) which I may bring into the hospital. It is suggested to leave these at home when possible.

Hospitals are required by Law to retain your clinical records for 10 years. In the event of destruction of records do you wish your record to be

  I have read and understand details under the heading 'Financial Details'. I acknowledge and will comply.