Patient Information Form Patient Survey Patient info Title * Mr Mrs Miss Ms OtherOther Known Name * Given First Name * Given Middle Name Given Last Name * Date of Birth (dd/mm/yyyy) * Occupation * Address Street Address * City/Town * Postcode/ZIP * https://www.nzpost.co.nz/tools/address-postcode-finder Postal Address Contact Number Mobile number Home number Work number Email Address Email * Would you like to receive email updates? Yes No Emergency Contact Next of Kin * Contact Number * Ethnicity Ethnicity * NZ European Māori Pacific Islander Asian Middle Eastern Latin American African Indian Prefer not to answer OtherOther Do we need to be aware of any cultural needs? Yes No If yes, please specify Cultural Needs * Healthcare Family Doctor's name Optometrist Do you have Medical Insurance? * Yes No If yes, please specify insurance company and policy number Insurance Company Policy Number Females Are you currently pregnant? Yes No Licences Do you have a pilot's licence? Yes No Do you have additional licence classes/endorsements ? Yes No Please state With or without glasses/contact lenses (whatever is usual for your), have you experienced any of the following during the last week: All of the time Most of the time Half of the time Some of the time None of the time N/A Eyes that are sensitive to light? All of the time Most of the time Half of the time Some of the time None of the time N/A Eyes that feel gritty? All of the time Most of the time Half of the time Some of the time None of the time N/A Painful or sore eyes? All of the time Most of the time Half of the time Some of the time None of the time N/A Blurred Vision? All of the time Most of the time Half of the time Some of the time None of the time N/A Poor Vision? All of the time Most of the time Half of the time Some of the time None of the time N/A Have problems with your eyes (with or without glasses/contact lenses whatever is usual for you) limited you in performing any of the following during the last week: All of the time Most of the time Half of the time Some of the time None of the time N/A Reading? All of the time Most of the time Half of the time Some of the time None of the time N/A Driving at night? All of the time Most of the time Half of the time Some of the time None of the time N/A Working with a computer? All of the time Most of the time Half of the time Some of the time None of the time N/A Watching TV? All of the time Most of the time Half of the time Some of the time None of the time N/A Have your eyes felt uncomfortable in any of the following situations during the last week: All of the time Most of the time Half of the time Some of the time None of the time N/A Windy conditions? All of the time Most of the time Half of the time Some of the time None of the time N/A Places or areas with low humidity (very dry)? All of the time Most of the time Half of the time Some of the time None of the time N/A Areas that are air-conditioned? All of the time Most of the time Half of the time Some of the time None of the time N/A Fendalton Eye Clinic Southern Cross Healthcare & nib Clients: We are an affiliated Southern Cross Healthcare provider and nib First Choice provider. If you meet the criteria for contracted procedures, we will organise approval and claim on your behalf. OUTSTANDING ACCOUNTS & Interest and debt recovery costs: Fendalton Eye Clinic Ltd reserve the right to charge interest on overdue amounts at 2% per month plus any debt recovery costs incurred. Consent to collect information: This medical practice collects information from you for the primary purpose of providing quality healthcare. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your healthcare needs. We will use the information you provide in the following ways: Administrative purposes in running our medical practice. Billing purposes, including compliance with Health Insurance Company requirements. Disclosure to others involved in your healthcare, including treating doctors and specialists outside this medical practice. I understand the reasons why my information must be collected.I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of healthcare and treatment given to me.I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances. I understand that if my information is to be used for any purpose other than the above my consent will be sought.I consent to the handling of my information by this practice for the purposes set out above subject to any limitations on access or disclosure of which I may notify this practice. Do you consent to the above? * Yes No Where did you hear about us ? Where did you hear about us ? Friend/Relative Google Website Facebook Radio Magazine Optometrist Yellow Pages reCAPTCHA If you are human, leave this field blank. Submit
