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  • PATIENT REGISTRATION/ADMISSION FORM

  • Are you completing this form for yourself?*

  • PERSONAL DETAILS

  • Prefix
  • Date of Birth:*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Sex at birth:*
  • Gender:
  • Citizenship:*
  • Ethnicity:

  • GENERAL PRACTITIONER

  • YOUR PREFERRED PHARMACY

  • EMERGENCY CONTACT

  • This is the person we will contact in case of an emergency. Please make sure this person is aware you are having this operation.
  • Do they live at the same address as you?

  • PAYMENT OF YOUR ACCOUNT

  • Prior to completing this section, you MUST have all your insurance/ACC pre-approval details.
    How will your appointment be paid?

  • Self-paying

  • If you are self-paying (paying for the total cost of your appointment) you will be responsible for all costs incurred and required to pay on the day of appointment. Our reception staff will be happy to take payment when you arrive or after your appointment.

  • Private Health Insurance

  • If your appointment is being funded by insurance, please ensure your insurer has pre-approved your appointment. If you are with Southern Cross or NIB, we can apply for your pre-approval on your behalf. For all other insurers, you will be asked to provide a copy of your pre-approval prior to your appointment. You will not have to pay for your appointment however you will be required to pay for your excess or co-payment depending on your insurance policy on the day of your appointment. A prompt claim from your insurer is appreciated. You may also be required to pay for other charges that are not covered by your policy.

  • Accident Compensation Corporation New Zealand (ACC)

  • You will be required to supply your letter of approval prior to your appointment. If your appointment has been approved by ACC your invoice for your appointment will be paid directly by ACC.

  • Methods of Payment

  • Our reception team can help you make your payment on your arrival using EFTPOS or Credit Card (Visa, Mastercard are accepted but please note there will be a 2.5% surcharge for credit cards). For Internet Banking, please make the payment to the account on the bottom of your invoice.
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  • PATIENT AGREEMENT

  • All patients to read and complete.

  • I give permission for G&H Cardiovascular and Kaweka Specialists to obtain any information relating to the approval/claim for this appointment from the relevant funder(s), and I authorise that person or organisation to disclose such information to G&H Cardiovascular and Kaweka Specialists. I accept that, in the event my account is not met, G&H Cardiovascular and Kaweka Specialists reserves the right to add all costs of collection to my account including legal costs and expenses incurred on a solicitor/client basis.

  • I acknowledge and agree that G&H Cardiovascular and Kaweka Specialists may, at its sole discretion (and without prejudice to any other rights or remedies available to it) require me to pay, on demand, default interest on overdue accounts at 2% per month, accruing on a daily basis from the date payment was due until the date of payment is actually made.

  • I acknowledge and agree I am liable for and hereby agree to indemnify G&H cardiovascular and Kaweka Specialists in respect of all costs and expenses which G&H cardiovascular and Kaweka Specialists may incur as a result of default in payment or any invoice by the due date, including legal costs and expenses incurred on a solicitor/client basis.

  • If I am signing this form on behalf of a minor in respect of treatment of that minor, I agree to pay upon demand accounts payable by that minor to G&H Cardiovascular and Kaweka Specialists from time to time.

  • I give permission to G&H Cardiovascular and Kaweka Specialists or any health professional (such as my medical specialist) involved in my care in relation to this appointment to access health information about me that is relevant to my treatment (including after discharge), which may be held by G&H Cardiovascular and Kaweka Specialists, other health professionals or other health organisations. I understand that a copy of my appointment letter and result will be sent to my GP and any other provider involved in my care. I understand any reports or clinic letters will be sent to the Cardiology Department at the DHB. I understand that other clinical team members such as student nurses and qualified medical trainees may have supervised involvement with my care and that I have the right to decline their presence or contribution to my care delivery.

  • I understand that my test results will remain confidential to me and relevant health professionals.
  • Completed by:
  • Date:*
     - -
    2 digit day, 2 digit month, 4 digit year
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