IMPORTANT:
Details of health insurance
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: 12-3244-0009208-00Particulars: Patient NameCode: Date of Surgery e.g. 12 Sep 2020Reference: 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 enter your comments in the box provided.
If Yes, please specify and describe the reaction using the box below.
Click the (+) button to add an item and (-) to delete an item.
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.
Do you use any of these personal items?
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.
Please verify the following information:
If any of the above information is incorrect, please return to the first page (step 1) to make the necessary updates.
The form submission may take up to 15 seconds. Please keep the browser open until you see the confirmation message.
If you're having trouble submitting the form, please use the 'Save and Resume' link below to save your progress. You’ll get a link you can copy or email to yourself, so you can return later or open it on another device. If the issue continues, please try using a different device, as your current one may not be compatible.