Patient Information Form

Title*
Date of Birth*

DayMonthYear
NHI Number
This is required by the DHB to access patient’s eligibility for funded laboratory testing relating to biopsies, not all patients are eligible for funded tests.
First Names (in full)*
Last Name*
Residential Address*
Suburb*
City*
Postal Code*
Phone
Mobile No*
Email*
Name of next of kin*
Relationship (eg. husband/wife)*
Phone*
Person responsible for fees*
Are you a NZ Resident?*

NoYes
Occupation
Do you have health insurance?*
Policy/Member Number*
Insurance Company & Policy Name*
If a third party such as medical insurance or ACC is involved in the reimbursement for your treatment, we remind you to confirm the situation with them before treatment commences.
Who referred you?*
Dentist's Name*
Dentist's Address*
Family Doctor's Name*
Family Doctor's Address*
Have you had any of the following?

(please tick yes or no)
Rheumatic Fever*

YesNo
Diabetes*

YesNo
Heart Ailments*

YesNo
Epilepsy*

YesNo
Kidney Disease*

YesNo
High Blood Pressure*

YesNo
Asthma*

YesNo
Hepatitis*

YesNo
Excessive Bleeding*

YesNo
Are you a smoker?
Are you likely to be at risk for AIDS or Hepatitis B?
Have you suffered any serious illnesss?
Please list any medical conditions
Have you had any previous operations?
Are you at Present:
1 - Receiving medical attention?
2 - Take medicines and tablets?
Please list names of drugs
Detail of any allergies
Gender*
Are you pregnant or breast feeding?
Preferred Surgeon
I give you permission to exchange information with my dentist, doctor and other medical or dental professionals.

I understand that any exchange of information will be confidential.

I agree to be contacted regarding aspects of my care.

Signature_________________ Date_________________
Should be Empty:

Have you had any of the following?