• Today's Visit is for*

  • Patient Details

  • Date of Birth*
     - -
  • Gender*

  • Ethnicity

  • Which ethnic group(s) do you belong to? Tick all that apply*

  • Residential Address

  • Contact Details

  • Community Service Card Holder (CSC)*
  • NZ Resident?*

  • Emergency Contact Person / Next of Kin

  • Family Doctor / GP

  • Do you have a regular Family Doctor you usually visit?*

  • Usual GP

  • The practice has a policy of forwarding a copy of your clinical notes to your identified Family Doctor (GP). If you DO NOT wish your clinical notes to go to your GP, please sign here

  • I would like my registered GP to get a copy of the records from this consultation*

  • Injury Form

    Please fill this section ONLY if you have had an injury. You may skip to the next page otherwise.
  • Have you seen a Doctor about this injury before?
  • Date of Injury
     - -
  • Accident occurred in New Zealand?
  • Moving Vehicle Accident?
  • Sports Injury?
  • Did the Injury happen at work?
  • Do you work?

  • Payment

    How will you be paying today?
  • Payment form*

  • Terms, Conditions & Consents

    Please read and sign to accept.

  • I declare that the information given in this form is true and correct, and that I have not withheld any information likely to affect my consultation. By signing this Form, I am agreeing to the terms & conditions of release of health information. I authorize Ponsonby Doctors to pass on parts of my information to the Ministry of Health and/or ACC.

    I understand that failure to settle fees immediately after consultation/treatment, Ponsonby Doctors reserves the right to forward the unpaid invoices to a Debt Collection Agency. Additional charges may apply for the debt collection process.

    (If applicable) I authorize the treatment provider to lodge this claim for me, the collection and release of any information about me to the extent that this is needed to prevent future injuries, determine cover and/or assess my entitlement to compensation, rehabilitation assistance, medical treatment and/or the appropriate level of care and personal attention that I should receive, ACC to contact anyone who holds relevant information, including external agencies or service providers (such as medical practitioners, specialist, New Zealand Police and Treatment Providers, IRD, WINZ, Assessment Agencies, employers and witnesses to the accident)

    We utilize a note taking tool called Heidi to accurately and efficiently capture the details of our discussions and the outcomes of our appointments. Heidi ensures that we can focus more on our conversation and less on manual note taking, enhancing the quality of care you receive.

    Your consent is crucial for us to use this technology. Please understand that your information will be handled with the utmost care, and Heidi’s use is aimed solely at improving your healthcare experience.

    Learn more about Heidi here

    By indicating your acceptance here and signing this consent form, you are agreeing to allow your clinician to use Heidi during your consultation.

  • I consent to my clinician using Heidi for my session*
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