Next of Kin/Emergency Contact Details

Do you have or have you ever had any of the following?

Please specify any cancer in your family (type and diagnosis)

Please list all of the medications you have taken in the last 4 weeks including dose and frequency.

This includes herbal or 'natural' remedies, vitamins and other supplements.

Terms & Conditions

Consultation

I understand that consultation may include a physical examination. If I object to this I will inform my consultant

Privacy Act

Pursuant to the Privacy Act 1993 and the Health Information Privacy Act 1994 the following is brought to your attention:

• The Registration Form collects personal information about you to assist Intus with your admission, treatment and care.
• This information is being received, collected and help securely by Intus Ltd, PO Box 36692, Merivale, Christchurch. De-identified data from your records may be registered into local, national or international databases for the purpose of improving clinical care.
• Failure to provide the medical information requested may compromise your care.
• You have the right of access to, and correction of, this information subject to the provisions of the Privacy Act 1993.
• The information supplied on the Registration Form may be forwarded to the New Zealand Health Information Service of the Ministry of Health. Data is used for statistical and research purposes in an aggregated form that does not identify individuals.
• Details of your relevant clinical notes may be shared with your insurance company and/or ACC for the purpose of evaluating your claim(s).
• Your clinical records may be provided to another registered medical practitioner involved with your care.

Payment

Accounts are due for payment within 7 days of invoice date. Payment is the responsibility of the individual receiving services. If you have any concerns regarding your account, please contact us within 7 days of invoice date.

Payment at time of service would be appreciated and may be made in cash, cheque, EFTPOS, Visa or Mastercard.

Insurance Claims

**Please forward all invoices promptly to your insurance company to enable them to process the claim**

Please note: Your insurer may require you to pay the invoice first, then submit your receipt for reimbursement.

Debt collection procedures will be initiated if the account is not paid within the specified period. This may include additional payment or a collection fee for the benefit of and enforceable by debt collection agency under the Contracts (Privacy) Act 1982.

Declaration

I confirm that I am the person that is registered on this form, or are authorised to do so as a guardian or person of authority.