Auckland Skin Laser Centre | New Patient FormAuckland Skin Laser Centre

New Patient Form

After you have phoned to make an appointment, please complete your new patient details below:

Date of your appointment*
DD slash MM slash YYYY
Title*
Name*
First Last
Preferred name (if different from First name)
Date of Birth*
DD slash MM slash YYYY
Physical Address*
Street Address Address Line 2 City
Postal Address (if different from physical address)
Street Address Address Line 2 City
NHI (Hospital) number
Phone (Home)*
Phone (Work)
Phone (Mobile)
Email*
Occupation
Next of Kin*
Next of Kin Relationship*
Next of Kin Address*
Street Address Address Line 2 City
Next of Kin Phone*
Family doctor (GP)
Family doctor address (suburb at least please)
Holder of medical insurance*
If yes, name of medical insurance company
Insurance policy type and policy number
Past skin problems (details please, including medications used or nil)*
Current or past medical problems and operations (details please or nil)*
Current medications (please list or nil)*
Allergies to medications (please list or nil)*
Source of referral*
Public health funding eligibility statement*
Due to health board requirements regarding laboratory tests and medication prescribing, we are required to ask this. If you are unsure, please contact reception for a list of eligibility criteria.
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