01
About you
Your legal name and a couple of details we use to find or create your patient record.
Who is this form for? *
Don't worry if you don't have this to hand.
02
Where you live
Your usual residential address.
Are you a resident of New Zealand? *
03
How to reach you
04
Emergency contact
Someone we can call if we're unable to reach you.
Your emergency contact cannot be you, and must be based in New Zealand.
05
Health cover
Do you have a Community Services Card? *
Do you have a High Use Health Card? *
Do you have an Emergency Q voucher? *
06
Your GP
Do you have a GP? *
Do you want your GP to receive a summary of your visit today? *
07
Today's visit
Tell us why you're here today.
Have you had an accident or injury? *
08
Consent
Please read and sign to confirm the details above are correct.
By signing this agreement, I acknowledge that I have read and understand the following terms and conditions:
- Ambulance Transfer Fees: I am responsible for paying any ambulance transfer fees incurred if I am required to be transferred.
- Additional Costs: I understand that certain services or medications may have additional costs that I will be responsible for paying.
- Electronic Notes: East Care's clinicians use an electronic notes assistant during consultations. These recordings are not saved or retained by East Care.
- Fee Responsibility: I agree to pay all fees associated with East Care's services, including any collection fees.
- ACC Claims: I understand that any claims not accepted by the Accident Compensation Corporation (ACC) are my responsibility and will be invoiced to me.
- Lab Results: I understand I will only be contacted about critical lab/blood results, and I am to follow up with my GP for all non-critical results.
· For further Terms and Conditions go to our website www.eastcare.co.nz.