Riddiford Medical Specialists Registration Form

Patient Registration Form

Please complete this form to assist us in arranging an appointment for a consultation for you. Leave blank any fields you cannot or prefer not to answer.
Riddiford Medical Specialists

19 Riddiford Street

PO Box 7662

Newtown Wellington

tel 04 8964510

reception@riddiford-medical.co.nz

www.riddiford-medical.co.nz
Name*

PrefixFirst NameMiddle NameLast Name
Preferred name
if different from First Name
Date of Birth*

DayMonthYear
Date
NHI
Sex / Gender*
Home Address*

Street Address

Suburb

City

Post Code
Ethnicity
Mobile Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Email*
example@example.com
Occupation
General Practitioner*
Or GP Practice Name
Preferred Pharmacy*
Health Insurance Scheme
Membership / Claim number
Contact / Next of Kin
Contact Details NOK
Phone or email
Allergies / alerts / warnings / things we should know about
Regular medications
Date

DayMonthYear
Health Information Privacy statement

Your personal health information and how it is used.

CONSENT REGARDING PATIENT HEALTH INFORMATION

I directly consent to my personal health information (patient data) being collected and stored confidentially by Riddiford Medical Specialists.

I understand that this health information may be confidentially shared with others involved in my healthcare, including my Insurance Provider and ACC.

I agree to receive medical and administrative correspondence by email, to the email address I have provided above.

SECURITY & PRIVACY OF PATIENT DATA

Patient data is stored securely and confidentially on the servers at Riddiford Medical Specialists in Newtown, Wellington. This data may be accessed by clinicians and staff working at Riddiford Medical Specialists.

Riddiford Medical Specialists may use AI-assisted transcription software to record consultation and procedure conversations and findings. This may mean that some health information is stored electronically by cloud service providers located in Australia. This information may also be processed (but not stored) on cloud servers located in other overseas countries. This information is encrypted at all times and these providers comply with internationally recognised security standards and New Zealand Information Privacy Principles (NZ IPPs)

Our processes are fully compliant with the Privacy Act 1993 and Health
Information Privacy Code.
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Patient Registration Form

Riddiford Medical Specialists

Health Information Privacy statement

SECURITY & PRIVACY OF PATIENT DATA