• Patient Information Form

  • Please complete the patient information form below and check our website for available appointments if you would like to make an appointment. This form must be completed for each patient prior to booking.
  • Have you already made an appointment at The Skin Hub?
  • Thank you for your interest in making an appointment at The Skin Hub. Please do not complete this form until you are making a booking.

     

    If you are going to make an apointment online or by telephone, please proceed with completing this form. 

     

     

  • Date of Birth*
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  • Gender*
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  • Ethnicity Details - Which ethnic group(s) do you belong to? Tick the space or spaces which apply to you*
  • Do you have a Community Services or Gold Card?
  • Transfer of Records - would you like us to request laboratory reports regarding previous skin surgeries or biopsies?
  • Previous records are helpful but we are happy to see you without them. If you would like to request a copy of your records from The Skin Clinic, please email info@theskinclinic.co.nz and ask for a copy to be sent to you and admin@skinhub.co.nz 

     

    If you do not hear back from The Skin Clinic, please contact the Ministry of Health. 

  • Would you like The Skin Hub to request a copy of your records from The Skin Hub on your behalf?
  • Do you have any allergies*
  • What is your skin type
  • Approximately how many times have you been badly sunburned in your life?
  • Southern Cross Information

    Southern Cross do not allow The Skin Hub to submit claims for routine appointments, including full skin checks. 

    For single spot checks, multi spot checks and surgeries, we can submit a claim on your behalf. For full body skin checks, we can submit a claim if you book an appointment due to particular concerns.

  • Our practitioners take digital photographs using a mobile phone owned by The Skin Hub and photographs are uploaded directly into your patient file on a secure app called Dermengine. Photographs are not taken of your scalp, breasts or genitals unless you have concerns and request them to be checked. The photographs are not stored on the mobile phone. Do you consent to our medical professional checking your skin and taking digital photography to assess lesions of concern? Please note that you are welcome to view or request a copy of your images for your records at any time.*
  • Digital photos will be taken during consultations. These are kept private, however they are sometimes shared with other medical professionals for referrals or teaching purposes. Do you consent to photos being shared for these purposes?
  • Our Privacy Statement can be viewed by clicking below (and is also available to view on our website, www.skinhub.co.nz)
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    PRIVACY STATEMENT

     

    The Skin Hub is committed to protecting your privacy and maintaining the confidentiality of your personal and health information. We collect, use, store and disclose information in accordance with the Privacy Act 2020, the Health Information Privacy Code 2020, and applicable professional and legal standards.

    Collection of Information

    We collect personal and health information that is necessary to provide safe, appropriate, and effective healthcare services. This may include:

    • Your name, date of birth, contact details, NHI number and other identifying information.
    • Medical history, medications, allergies, family history and clinical information.
    • Photographs and dermoscopic images taken for diagnostic, treatment and monitoring purposes.
    • Information relating to appointments, billing and health insurance claims.

    Where possible, we collect information directly from you. However, we may also receive information from other healthcare providers, family members, referrers, insurers, laboratories, specialists, hospitals, pharmacies, Health New Zealand, or other organisations involved in your care.

    Where information is collected from a source other than you, we will comply with our obligations under Information Privacy Principle 3A and notify you of that collection where required by law.

    By accepting health care services from us, you agree to health information mentioned above may be collected by The Skin Hub. If information is collected from another source, we will inform you providing no exceptions apply under the Health Information Privacy Code apply.

    Use of Information

    Your information may be used to:

    • Assess, diagnose and treat health conditions.
    • Communicate with you regarding appointments, results and follow-up care.
    • Coordinate your care with other healthcare providers.
    • Process ACC claims and insurance-related requests.
    • Meet legal, professional and regulatory obligations.
    • Improve the quality and safety of our services through clinical audit, quality assurance and staff training.
    • Manage administrative and business functions of the practice.

    Disclosure of Information

    We will only disclose your information where:

    • You have authorised the disclosure.
    • The disclosure is necessary for your ongoing care or treatment.
    • The disclosure is required or permitted by law.
    • The disclosure is necessary to prevent or lessen a serious threat to health or safety.
    • The disclosure is required for ACC, health insurance, regulatory, audit or funding purposes where authorised or permitted by law.

    Where clinical information is requested by an insurer, we will generally seek your written consent before releasing information unless another lawful basis for disclosure applies. We often receive requests from insurers with authorisation from patients to release information. Please be aware that you may have agreed to this when agreeing to the terms and conditions of your insurance policy.

    Digital Photography and Clinical Images

    Clinical photographs and dermoscopic images may be taken to assist with diagnosis, treatment planning, monitoring and comparison over time. Images are securely stored within your medical record and are treated as health information. Images are only accessed by authorised personnel involved in your care.

    Storage and Security

    We take reasonable steps to protect your information from loss, unauthorised access, use, modification or disclosure. Information is stored within secure electronic medical record systems and may be held by trusted service providers who assist us in delivering healthcare services. Where information is stored or accessed outside New Zealand, we will ensure appropriate safeguards are in place as required by law.

    Access and Correction

    You have the right to request access to your personal and health information and to request correction of information you believe is inaccurate. Please feel free to request a copy of your records, either by emailing admin@skinhub.co.nz, by phoning us on 03 242 6088, or in person at the clinic.

    Retention of Information

    Health information is retained for the period required by applicable legal, professional and regulatory requirements and is securely disposed of when no longer required.

    Staff Confidentiality

    All staff are required to maintain strict confidentiality. Access to patient information is limited to authorised personnel who require the information to perform their duties. Unauthorised access, use or disclosure of patient information may result in disciplinary action and may constitute a breach of privacy legislation.

    Questions or Complaints

    If you have any questions about how your information is handled, or if you believe your privacy has been breached, please contact our clinic manager. If you are not satisfied with our response, you may contact the Office of the Privacy Commissioner.

    This privacy statement may be updated from time to time to reflect changes in legislation, professional standards and practice operations.

     

     

  • I agree to my health information being collected, used, and disclosed in connection with my healthcare as outlined in The Skin Hub's Privacy Statement*
  • Please contact us if you have any questions regearding your health information being collected, used, and disclosed in connection with your healthcare.

     

    We are happy to answer any questions you may have or provide further information. 

     

    We may not be able to offer you our healthcare services, but are happy to discuss your options with you.

     

    You are welcome to email admin@skinhub.co.nz phone us on 03 242 6088 furing our opening hours. 

     

     

  • Do you have difficulty with any of the following? Please select all that apply
  • We care about your needs. If you have any special requests or suggestions as to how we can support you, please do not hesitate to ask.

     

    You are welcome to bring a support person or request a chaperone for your appointment at The Skin Hub. You may request a chaperone by emailing, phoning or speaking to our staff in person.

  • Would you like to receive occasional email updates from The Skin Hub?
  • If you have been referred to The Skin Hub, who referred you (leave blank if you have not been referred):
  • Signed by
  • Date
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  • Should be Empty: