Da Vinci Plastic Surgery New Patient Form

Da Vinci Plastic Surgery New Patient Form
Please type in your unique 5-digit clinic ID number that you were provided with when you made your appointment.
Enter Clinic-ID Here*
Code contains 5 digits
Please select your Doctor
Your Title
Name

First NameLast Name
Date of birth

DayMonthYear
Date
Address

Street Address

Street Address Line 2

City

Postal Code
Home number

Area codeNumber
Mobile number

021, 027...Number
Work number

Area codeNumber
Email
example@example.com
Family Doctor
Referring Doctor
Occupation
Medical Insurer
If your appointment relates to an ACC injury we require the following:
ACC claim number
Date of injury

DayMonthYear
If patient is a dependant child:
Name of parent
How did you come to hear of Da Vinci Clinic, Mr Adam Bialostocki, Mr Brandon Adams or Mr Dan Butler?*

NZ Association of Plastic Surgeons websiteGoogleDa Vinci Clinic websiteUNO MagazineYellow pagesGP ReferralNewspaperFacebookFriend or family memberLectureReferred by DoctorOther
Current medications
Previous surgery
Drug Allergies
Do you smoke?

YesNo
Never smoked

Never smokedEx SmokerYes, enter qty below
Quantity of cigarettes per day
Do you vape?

YesNo
Quantity of vapes per day
Do you regularly take any of the following:

Cartia / Aspirin / AspirinAnti-coagulants (eg. Warfarin Pradaxa Clopidogrel) Non-prescription medicines such as Fish oils garlic arnica or Marijuana. Please specify below:
Anti-coagulants:
Non-prescription medicines such as Fish oils garlic arnica or Marijuana. Please specify below:
Non-prescription medicines:
Do you have any of the following:

Rheumatic feverHeart ConditionsHeart PalpitationsIrregular heart beatChest painsShortness of breathSwelling of anklesHigh blood pressureCold soresDiabetesCancerKidney ConditionsEye diseasesEye DrynessHepatitis / HIVThyroid ProblemsAsthmaSkin disordersBleeding disordersBlood clotsAnaesthetic problemsPsychiatric disordersKeloid / hypertrophic scars
If you have come for a Cosmetic Consultation, what aspect of your appearance would you like to discuss today?
Newsletter

Please tick if you do not wish to receive our quarterly newsletter
Following your consultation, a letter is usually sent to your Doctor to keep him/her informed. If for any reason you would prefer this letter NOT to be sent, please tick the box below.

Please don't send letter
- For some sensitive examinations, a Chaperone will be present.
- Any unpaid accounts will incur late payment fees. If your account is sent to a debt collection agency, these collection costs will be added to the debt and will become the responsibility of the debtor.
- To help ensure accurate and detailed notes, we may use secure intelligent transcription tools during your consultation. By clicking I agree below, you consent to this as part of your care.
- I consent to the taking and secure storage of clinical photographs for accurate documentation and complete medical records. They will not be used for publication, education, or advertising without separate written consent.
Should be Empty: