Wound Care Patient Initial Intake Form 伤口护理患者初次登记信息表
Level 13, 175 Queen Street, Auckland 1010 Phone: 095539888 Email: admin@unitycare.co.nz
Patient Information
患者信息
Name 姓名
*
First Name 名
Last Name 姓
NHI if Known 医疗号码 如果不知道可以跳过
Who is your GP 你的家医是谁?
Date of Birth 出生日期
*
-
Day
-
Month
Year
Date 日期 日-月-年
Gender 性别
Male 男
Female 女
Prefer not to say 不愿透漏
Other 其他
Phone Number 手机号码
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email 邮箱地址
*
example@example.com
Is this related to ACC 这与ACC相关吗?
*
Yes
No
If Known existing ACC number please put in the box 如果您现已有ACC号码 请填写在下方
Please attach photos of your wound 请附上您伤口的照片
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Are you taking/applying any medications for your wound 您是否在您的伤口上服用/涂抹任何药物?
*
Patient Signature 签字
*
Submit
Should be Empty: