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Patient Information Form

Patient Survey

Patient info

Title *

Address

Contact Number

Email Address

Would you like to receive email updates?

Emergency Contact

Ethnicity

Ethnicity *
Do we need to be aware of any cultural needs?
If yes, please specify

Healthcare

Do you have Medical Insurance?
If yes, please specify insurance company and policy number

Females

Are you currently pregnant?

Licences

Do you have a pilot's licence?
Do you have additional licence classes/endorsements ?
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?
Eyes that feel gritty?
Painful or sore eyes?
Blurred Vision?
Poor Vision?
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?
Driving at night?
Working with a computer?
Watching TV?
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?
Places or areas with low humidity (very dry)?
Areas that are air-conditioned?

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:

  1. Administrative purposes in running our medical practice.
  2. Billing purposes, including compliance with Health Insurance Company requirements.
  3. 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?

Where did you hear about us ?

Where did you hear about us ?

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We are proud to announce

Fendalton Eye Clinic is one of a handful of ophthalmology centres in New Zealand to have achieved the New Zealand Standards NZS8165 Rooms, Office-Based Surgery and Procedures Standard.

Achieving this standard reflects the dedicated and hard work of the team at Fendalton Eye Clinic and our commitment to delivering the highest standard of patient care.