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Patient Registration

Your legal name *
Your preferred name (if different from above)
Title *
Your date of birth *
Your phone number *
Address line 1 *
Address line 2
City *
Postal Code *
Email address *
NHI number if known
Name of next of Kin *
Relationship of your next of Kin *
Next of Kin phone number *
How did you hear about us? *
If you selected other, how did you here about us?
Name of referring doctor and practice
Name of GP if different to above
Your occupation *
Your ethnic group *
What problem are you seeing the doctor about? *
How long have you had this? *
Previous breast surgery? If so, when?
Family history of cancer? Please state relationship, type of cancer and age of diagnosis.
Have you had any children? What ages are they? Did you breastfeed?
Date of last menstrual period? Or have you had a hysterectomy? *
Please list all medications including herbal remedies, HRT & contraceptives.
Any allergies to medication? Any other allergies? Please give details.
Are you taking Aspirin or anti-inìammatories? *
Do you smoke? *
If YES, how many per week?
Do you drink alcohol? *
If YES, how many per week?

Do you have, or have you ever had…

Heart problems *
Asthma *
Hepatitis *
HIV Positive *
Stroke / TIA *
Rheumatic Fever *
Epilepsy *
High Blood Pressure *
Diabetes *
Clots in Legs or Lungs *
When you sustain a cut do you stop bleeding normally? *
Have you had any problems with anaesthetics? *
When was your last mammogram? Where was it done? *
Medical Insurance Provider and Policy Number *
Correspondence may be sent to me by email/text *
Are you entitled to free hospital care in New Zealand? *
Do you have any cultural needs?

 

Consent

Your legal name *
Signed *

 All personal information collected by Breast Associates is treated with respect and remains confidential. Breast Associates may share your information with other Clinicians involved in your care, or use your unidentifiable data for audit or scientific purposes. Any third party invoices (e.g. laboratory fees) may be passed on to the patent for payment. A chaperone is available on request. If there are any questions that do not apply please leave it blank.

 

 

 

CONTACT US

Breast Associates | Ascot Central, 7 Ellerslie Racecourse Drive, Greenlane, Auckland, New Zealand.

 
Ph +64 9 522 1346 | info@breastassociates.co.nz

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