Check in · East Care

About you

Your legal name and a couple of details we use to find or create your patient record.

Who is this form for? *

Myself

A child/minor <16yrs old

Title

Given name *

Middle name(s)

Family name *

Preferred name(s)

Date of birth *

NHI number

Don't worry if you don't have this to hand.

Assigned sex at birth *

Gender *

Country of birth *

Primary ethnicity *

Where you live

Your usual residential address.

Street number and name *

Suburb *

Town / city *

Postcode *

Are you a resident of New Zealand? *

Yes

How to reach you

Mobile phone *

Email address *

Work phone

Home phone

Emergency contact

Someone we can call if we're unable to reach you.

First name *

Last name *

Relationship *

Phone number *

Your emergency contact cannot be you, and must be based in New Zealand.

Health cover

Do you have a Community Services Card? *

Yes

Do you have a High Use Health Card? *

Yes

Do you have an Emergency Q voucher? *

Yes

Your GP

Do you have a GP? *

Yes

Do you want your GP to receive a summary of your visit today? *

Yes

Today's visit

Tell us why you're here today.

Why did you come to East Care today? *

Have you had an accident or injury? *

Yes

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.

Sign here

I confirm the information I've provided is accurate, and I consent to East Care using it to provide my care today.