IMPORTANT:

• The questionnaire must be completed in one sitting; please ensure you have sufficient time, as it may take a while to complete.
• We need to receive your patient admission forms at least one week before your admission, although receipt as early as possible is appreciated.
• Any field marked with a * is a mandatory field. The form can not be submitted until all mandatory fields are completed.
• By clicking Submit at the end of this form, all entered data will be sent to North Shore Surgical Centre. A copy of this form will also be sent to the email address entered in this form. To ensure privacy and safe delivery, please be sure to enter your email address correctly.

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Additional charges

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.

Payment prior to surgery

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.

Methods of payment

We accept payment by EFTPOS, VISA, Mastercard, UnionPay or internet banking. Personal cheques are not accepted. We prefer not to receive payment by cash.

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: