Hamilton Eye Clinic » Patient Information » Patient RegistrationPatient Registration If you are a new patient, please fill in this form to register as a patient at Hamilton Eye Clinic. If you have any questions about this form, please phone us at 07 834 0006 and we'll be happy to assist you. Which specialist would you like to see?*Please SelectDr Benjamin HoyDr Bheema PatilDr David WorsleyDr James McKelvieDr John DicksonDr Michael MerrimanDr Rohan WeerekoonDr Selma MatloobDr Stephen GuestDr Stephen NgI don't know Your DetailsTitle*Please SelectMrMrsMsMissDrOtherFirst Name(s)*Surname*Second/Third NamesPrevious Name(s)Gender*Please SelectMaleFemaleDate of Birth* Date Format: DD slash MM slash YYYY Ethnicity*Are you a New Zealand resident?*YesNoNHI Number (If Known)Residential Address*Postal Address*Same as aboveDifferent Postal AddressPostal Address*Primary Phone Number*Phone (Mobile)*Same As Primary Phone NumberPhone (Home)*Same As Primary Phone NumberPhone (Work)Email Next of Kin DetailsNext of Kin*Relationship*Phone Number*Email AddressHealth DetailsHealth InsurerMembership NumberACC NumberFamily Doctors (GP)PracticeOptometristOptometrist Clinic Health ConditionsBlood Clots*YesNoAnaesthetic Problems*YesNoDiabetes*YesNoAnxiety Disorder*YesNoInsulin*YesNoStroke*YesNoHigh Blood Pressure*YesNoStomach Ulcer*YesNoHeart Condition, Angina*YesNoMRSA (Golden Staph)*YesNoHeart Murmur*YesNoHepatitis*YesNoSmoking*YesNoExposure to HIV/AIDS*YesNoAsthma*YesNoPoor Hearing*YesNoBleeding Problems*YesNoEpilepsy*YesNoMigraine*YesNoAre you taking Asprin?*YesNoAre you taking Warfarin?*YesNoCancer*YesNoAllergies*YesNoPlease specify type of cancer*Please state your allergies*Do you have any other serious illness or major condition? (Please state)Please list all current medications that you are takingPrevious Eye OperationsApproximate DateAll Current Medications Consent* By clicking submit, you agree/consent to our terms and conditions for storage of your health information.CommentsThis field is for validation purposes and should be left unchanged.