Registration Form - Auckland ENT

Please check and complete the following details:

Title

NHI

Legal Name

Preferred Name

Last Name

Date of Birth

Work Ph

Mobile

Home Ph

Physical Address

Billing Address

Ethnicity

Occupation

Insurance Company

Membership#

GP's Name & Clinic

Referring Dr

Emergency Contact + Mobile

List any Allergies

Current Medication

Is this visit related to ACC?

Yes No

Claim #

(Preferred Pharmacy) Pharmacy Name:

Contact Details:

Permission to Collect and Store Information

We need to collect and store some information about you: to help us provide good and safe treatment and to provide Government bodies with information to which they are legally entitled.

We undertake: only to collect information which is appropriate to your total care, only to use the information for its intended purposes, to keep the information in your medical file and/or in our computer system, only to allow authorised staff to use that information, only to pass on to government bodies that information to which they are legally entitled, to allow you to check the accuracy of any information about you and to submit written corrections which you feel appropriate.

Auckland ENT Group Terms and Conditions:

I agree to settle my account with Auckland ENT Group in full at the time of my consultation / surgery when personally paying my account or where I do not have “prior approval” in full from my insurer. I understand I am responsible for any outstanding balance if my procedure is not FULLY covered by insurance, ACC or any other contract. I give permission for Auckland ENT Group to obtain any information relating to the approval/claim for this admission/procedure from the relevant funder/s, and I authorise that person or organisation to disclose such information to Auckland ENT Group. I accept that in the event my consultation/procedure or operation account is not met, Auckland ENT Group reserves the right to add all costs of collection to this account.

I have read the above explanation and agree to the collection and storage of information and the terms and conditions.

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Patient Information

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242 Great South Road
Greenlane
Auckland

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Procedures

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Auckland ENT Group © 2021 All rights reserved

Developed and Designed by AMPM Web & Digital

Patient Information

Please check and complete the following details:

Enquire now

242 Great South Road Greenlane Auckland

Menus

Quick Links

Procedures

Conditions

Menus

Quick links

Procedures

Conditions treated

Auckland ENT Group © 2021 All rights reserved

Developed and Designed by AMPM Web & Digital

242 Great South Road
Greenlane
Auckland