New Patient Registration - Christchurch Dermatologists, Dermatologic Surgeons, KM Surgical Christchurch NZ

Reason for your consultation *

Personal Information

Title *

First names *

Surname *

Preferred name (optional)

Parent/Guardian name(s), if the patient is under the age of 16

Date of Birth *

Please enter in DD/MM/YYYY format.

Occupation *

NZ Resident *

Ethnicity (optional)

Home Address *

Postcode *

Your contact phone number *

Email *

Medical Information

Next of Kin Name *

Next of Kin Phone Number *

Do you have medical insurance? *

General Practitioner/Family Doctor *

Referring Doctor (if different)

Please list your prescribed medications including herbal/health supplements *

Enter 'None' if you have no prescribed medications including herbal/health supplements.

Please list important health problems/medical and previous surgical conditions *

Enter 'None' if you have no important health problems/medical or previous surgical conditions.

Please list any allergies/medication side effects *

Enter 'None' if you have no allergies/medication side effects.

Newsletter

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Terms, Conditions and Permissions

Terms of Trade, Payment and Booking Policy

Payment is required on the day of consultation/treatment unless you have medical insurance or you have made prior arrangement with the Business Manager. 24 hours’ notice is required for cancellation of your appointment, otherwise a non-attendance fee of $75 will be charged. For all surgical appointments, cancelled/non-attended within 24 hours, a 20% of the surgery fee will be charged. All bad debts will be sent onto Baycorp Debt Collection, additional collection fees will apply.

I agree to settle my account in full, or where I do not have “prior approval” from my insurance provider.

Permission to record and store information

KM Surgical collects personal information which is appropriate to your medical care and treatment. This information is secure. Only authorised staff are permitted to use your health information. You have the right to request access to your health information and the right to request correction of your health information. You consent to us otherwise using or disclosing information in accordance with the Health Information Privacy Code 1994.

I have read the above and agree to the Terms of Trade, Payment and Booking Policy, and the Collection and Storage of Information. I understand that photographs may or may not be taken of myself and held on your photograph database for purposes of medical records or any other relevant or incidental purpose set out in the Health Information Privacy Policy.

Dermatology Notice

& Dermatology Associates

New Patient Registration Form

Fields marked with an * are required.