patient registration form

Your details

Specialist Name (your Dr)

Title

First names

Last name

Preferred name

Previous name

Gender

Date of Birth

Ethnicity

NZ resident

NHI Number

Residential address

Postal address

Primary phone number

Phone (mobile)

Phone (home)

Phone (work)

Next of Kin details

Next of Kin

Relationship

Phone number

Health details

Health insurer

Membership number

ACC number

Family Doctors (GP)

Practice

Optometrist

Optometrist Clinic

Health Conditions

*Tick conditions that apply to you

Cancer

Allergies

Do you have any other serious illness or major condition?

Have you had any previous eye surgeries? (Yes/No)

If yes, please list the type of surgery and the date(s) it was performed

Were you prescribed any medications after your eye surgery(ies)? If yes, please list the medication(s)

Please list all current medications that you are taking

Permission to contact by Phone

Permission to contact by Email

Contact preference

Thanks for completing patient registration form, we have received it and will get back to you within 2 working days using the preferred contact details you provided.

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