IMPORTANT:
If you are not a New Zealand resident, you will be asked to complete the "Acknowledgement Form: Non-NZ resident" on admission.
Telephone:
Depending on your health insurance policy or plan you may be required to pay an excess (co-payment). You may also be required to pay for some charges that are not covered by insurance, ACC or DHB.
You may be asked to pay a deposit before admission. The amount is based on the estimated cost of the procedure payable by you not otherwise covered by your insurance, ACC or DHB. The deposit will be refunded to you if the procedure is cancelled.
We accept payment by EFTPOS, VISA, Mastercard, UnionPay or internet banking. Personal cheques are not accepted. We prefer not to receive payment by cash.
Internet Banking Details
Payee: North Shore Surgical Centre
Bank a/c: 12-3244-0009208-00
Particulars: Patient Name
Code: Date of Surgery e.g. 12 Sep 2020
Reference: NSSC
I agree to settle my hospital account in full at the time of my discharge when personally paying my account or where I do not have “prior approval” from my insurer. I understand I am responsible for any outstanding balance if my procedure is not fully covered by insurance, ACC or other contract.
I give permission for North Shore Surgical Centre to obtain any information relating to the approval/claim for this admission from the relevant funder/s, and I authorise that person or organisation to disclose such information to North Shore Surgical Centre. I accept that, in the event my hospital account is not met, North Shore Centre Centre reserves the right to add all costs of collection to this account.
I give permission to North Shore Surgical Centre or any health professional (such as my medical specialist) involved in my care in relation to this admission to hospital, to access health information about me that is relevant to my treatment (including pre-admission and after discharge), which may be held by North Shore Surgical Centre, other health professionals or other health organisations. I understand that other clinical team members such as student nurses and qualified medical trainees may have supervised involvement with my care and that I have the right to decline their presence or contribution to my care delivery.
I understand the admitting Surgeon, Anaesthetist and other Doctors or health professionals using North Shore Surgical Centre facilities are independent and not employees of North Shore Surgical Centre, with respect to both my treatment, care and account payment. I accept that this agreement is covered by New Zealand law. The details above have been completed by:
Please complete this questionnaire carefully as the information you supply helps us to provide you with the best and safest possible care during your stay at our hospital. The questionnaire has four sections:
A Your general health
B In preparation for your hospital admission
C In preparation for your procedure
D Your current medicines
All questions in this questionnaire are about the person being treated at the hospital (the patient). If you are filling this out for the patient, only provide information relating to the patient’s health.
Do any of the following apply to you?
Do you currently have, or have you previously had, any of the following conditions?
If yes, please tick any applicable options and provide your comments in the box below.
17. Breathing conditions
18. COPD Sleeping conditions
19. Heart conditions
20. Stroke or Transient Ischemic Attack (TIA)
21. High blood pressure or blood pressure controlled with medication
22. Blood clots
23. Family history of blood clots
24. Blood or bleeding conditions
25. Family history of blood or bleeding conditions
26. Stomach and digestive conditions
27. Bowel conditions
28. Liver disease
29. Kidney conditions
30. Diabetes
31. Thyroid conditions
32. Parkinson's disease
33. Epilepsy, seizures, blackouts or fainting
34. Migraines or severe headaches
35. Alzheimers or dementia
36. Mental function conditions
37. Mental health conditions
38. Emotional conditions
39. Arthritis
40. Neck or back conditions
41. Gum or dental health
42. Tuberculosis (TB)
43. HIV or AIDS
44. Infection or treatment for resistant organisms
45. Cancer
If Yes, please specify and provide details of any recent treatment in the comments section below.
46. Other condition(s) not listed above
If Yes, please specify in the comments section below.
If Yes, please specify and describe the reaction using the box below.
Skin-related
Medicine-related
Others
Please answer the following questions to help us to tailor how we care for you.
If you answer Yes to any of these questions, we may contact you to discuss your specific needs.
If Yes, please outline your previous admissions below.
Do you use any of these personal items?
If you answered ‘Yes’ to questions 61-63, please use the textbox below to provide any additional details.
If Yes, please discuss with your nurse or medical specialist when you arrive at the hospital.
For your safety, it is extremely important that your doctor and nurses know precisely which medicines you are currently using.
Important instructions.
1. List below all medicines you currently use, and bring them with you to the centre in their original containers.
2. If you are taking any blood thinning medication or supplements, check with your surgeon if these need to be stopped prior to your admission .
3. If you have a medication card or printout from your GP or pharmacist, please bring it with you to the centre, as well as completing the list below.
List all medicines you currently use.