Call Us Now 07 858 0772 HOME FACILITIES CONDITIONS WE TREAT PATIENT INFO OUR SURGEONS FORMS & INFO CONTACT Patient Registration Form – Testing Only 1Personal Details2Contact Details3Medical Details Part One4Medical Details Part Two5Terms Names First Middle Last Title Mr Mrs Miss Master Ms Dr Prof Preferred NameGender Male Female Gender Neutral Other Date of birth Day Month Year Please specify: Home Address Street Address Address Line 2 City Post Code Postal Address My postal address is different to my home address Postal Address Street Address Address Line 2 City Post Code Email Receive email correspondence at this address? Yes No Mobile PhoneWork PhoneHome PhoneEmergency contact nameRelationship to contactEmergency contact phone numberIf patient is a dependant child, please supply name of parents(s) / guardians(s) GP NameGPs Medical CentreReferring DoctorReferring Doctors Medical CentreHealth InsurerMembership NumberYour occupation(Required) Previous illness/surgeriesDo you take any of the following medication regularly? Aspirin Aspro Disprin Cartia Warfarin Dabigatran Clopidogrel Biloba Gingko Vitamin E Arnica Omega/fish oils Another blood thinning medication Please SpecifyCurrent medicationsPlease include non-prescription/herbal medications - e.g. garlic, arnica, fish oil or others. Attach list below if necessary. Upload details of medicationAccepted file types: pdf, doc, docx, txt, jpg, png, heic, webp, Max. file size: 2 MB.Do you have any allergies? No Yes Please provide details of your allergiesDo you smoke or vape? No Yes Ex Smoker Number per day Terms & Conditions I agree to the terms of trade.These are for testing purposes only. Endoscopy on Clarence provides medical consultations and procedures under the following conditions: 1. Appointments: Patients agree to attend booked appointments or provide at least 24 hours’ notice for cancellations. 2. Medical Advice: Information provided during consultations is for individual medical guidance and should not be shared or applied to others. 3. Results & Follow-Up: Patients are responsible for attending follow-up appointments and collecting results where required. 4. Privacy: All patient information is handled confidentially in accordance with New Zealand privacy laws. 5. Fees & Payments: Payment is due on the day of service unless prior arrangements are made. 6. Liability: While every effort is made to ensure safe and effective care, Endoscopy on Clarence is not liable for unforeseen complications arising from procedures or non-compliance with medical advice. By attending your appointment, you agree to these terms.
