Patient Form - hamiltonortho.co.nz

HEALTH PROFESSIONALS DETAILS

Patient Name: *

Date *

GP Name: *

GP Practice: *

Current Physiotherapist:

Have you had other Treatment for problem: *

Current Pharmacy (for future scripts please): *

Imaging: current or previous date:

Imaging Location:

EMERGENCY CONTACT/NEXT OF KIN:

Name *

Relationship: *

Phone *

FUNDING INFORMATION:

Please select ONE of the Following: *Self FundingPrivate InsuranceACC

If this is a private insurance claim please provide your:

Company:

Policy Number:

Patients seen by Hamilton Orthopaedics are considered to be responsible for their own accounts unless funded by ACC and are required to pay for consultations on receipt of an invoice which will be emailed to them following the consultation.

Private and Insured patients charges are set out below.Initial consultations range in price from $250.00 -$315.00, with follow up consultations ranging from $155.00

-$205.00.

Self funded patients requiring surgery shall pay the surgical fee component of their estimate 14 days prior to the

day of their operation.

MEDICAL HISTORY:

It is important that we are aware of any other medical concerns or conditions that may influence your ongoing care. As a private medical provider we do not have access to your health records. So we are able to treat you safely please provide the below information. Please check spelling if you are unsure.

Medical concerns/conditions: *

Allergies: *

Medications: *

Current Pain Medications: *

SOCIAL HISTORY:

Living Situation: *I live aloneI live with my partnerI have flatmates/ house share

Occupation: *

CONSENTS

Please take your time reading the following consent and agreement information. This allows us to treat you to

the best of our ability with all the information at hand. If you require clarification or assistance, please see the

administration staff or your treatment provider.

In compliance with the Privacy Act, all information recorded in our health system regarding your treatment will

be kept confidential. Your records will only be viewed by the Doctors and Nurses providing your care and the

reception staff at Hamilton Orthopaedics clinic office. We maintain strict confidentiality unless consent provided.

CONSENT TO SHARE MEDICAL INFORMATION *I consent to sharing my medical information regarding my treatment and condition, to ensure efficient and accurate treatment. I understand information will only be shared with other health professionals/clinics, insurers or other funding agencies such as ACC. I give consent for Hamilton Orthopaedics to request my medical records from my GP and/or other medical providers.Please tick here to consent to the above

CONSENT FOR TREATMENT *I agree to receiving treatment for my condition that I am presenting at the time of my appointment. I understand that a verbal explanation will be given during treatment. I have the right to decline treatment that has been offered to me.I consent to the treatment

AGREEMENT TO PAY *I understand my treatment at Hamilton Orthopaedics may come with a charge if not fully covered by an insurer or ACC. Therefore, I understand that I am liable to pay for: Any private treatment or co-payment fees for ACC and Insurers. Any additional private treatment not covered by ACC/insurance. E.g. Injections. Any self funding costs for consultations, procedures or surgery. If a debt collection service is required to recover my debt, I will be liable for all recovery fees. A "did not attend fee" , if I fail to attend my appointment without 24 hours prior noticeI consent to pay in above