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Patient Admission

NOTE: this form is not currently compatible with mobile phones, tablets or iPads. Please complete using a desktop or laptop computer only. Alternatively collect a paper form from Grace Hospital main reception - open Monday - Friday 7am to 8.30pm.

Before starting this Patient Admission Form, you will need to have the following information at hand:

List of medications and/or supplements you are currently taking (including dose/frequency)
Previous hospital admission history (from any hospital) in last 10 years
Your height and weight
Insurance membership and pre-approval claim number (if applicable)

Please enter "unknown" for any mandatory fields you may not yet have answers to.

For your security, the information you provide in this form will be deleted from this website upon submission of this form. A copy of this form will be emailed to you upon submission and we suggest you save a copy of that email for your records.

If you have any questions about this form, please do not hesitate to contact us at 07 577 5270.

If you have already registered an account, you must login here to re-use this form.
Your Details
- Title
- Surname*
- Previous Surname
- Legal First Names*
- Preferred First Name
- D.O.B*
- Gender
- NHI Number
  If you are unsure please leave blank
- Occupation
- NZ Resident*
- Ethnicity
- Language
Contact Details
- Home Address*
- Postal if different
- Home Phone
- Work Phone
- Mobile No.
- Email Address*
Emergency/Next of Kin Contact Details
- Name
- Relationship to Patient
- Address
- Home Phone No.
- Work Phone No.
- Mobile Number
- Post-op Contact Name:*
  The person who will pick you up following your procedure
- Post-op Contact Number:*
  The person who will pick you up following your procedure
Preferred Method of Communication
- Preferred Method of Communication*
  Text
  Email
  Phone ( morning )
  Phone ( afternoon )
  Phone ( evening )
Surgeon and Surgery Details
- Date of Surgery*
- Surgeon*
- Surgeon 2 ( if required )
- Procedure 1:*
- Procedure 2 ( if required )
Doctor/Pharmacy/Medical Centre Details
- Medical Centre*
- GP*
- Pharmacist*
Funding of your Surgery
- Please select one:*
Insurance Company or Other Funder
- Company Name:
- Membership No.
- Approval No.
- Insurance Excess (amount if known ) $
Payment Method
- Payment Method
  Internet Banking
  Credit Card
  Cash or EFTpos Payment
Internet Banking Details
Bank Account: 03 0584 0283955 00 Norfolk Southern Cross Limited
Please use patient name and surgery date as the transaction reference when making any internet payment
Patient Declaration
( patients will sign for this on the printed form )
I understand:
- that the admitting consultants and anaesthetists using Grace Hospital facilities are independent practitioners who are not employees of Grace Hospital. I understand I have a direct relationship with them in respect to treatment, care and payment of their accounts.
- that I am responsible for any other costs associated with my stay i.e. ambulance, radiology, additional costs due to treatment complications not covered in my estimate and not covered by medical insurance, ACC or other funder.
- that I will pay any estimated personal payment or insurance excess at least 3 days prior to admission.
- that collection costs and interest may be added to any overdue account.
- that while every care will be taken with my essential items e.g. spectacles, watch etc, I should leave other valuables at home, as Grace Hospital is unable to take responsibility for these items.
I give permission to Grace Hospital or any other health professional involved in my care for this admission to hospital, to access health information about me that is relevant to my treatment, which may be held by Grace Hospital, other health professionals or other health organisations.
- I agree and have understood the above statement
Do you have or have you had any of the following? Please complete all the questions either Yes or No.
- High Blood Pressure*
  No
  Yes
- Heart Attack*
  No
  Yes
- Heart Murmurs*
  No
  Yes
- Artifical heart valve*
  No
  Yes
- Pacemaker*
  No
  Yes
- Chest pains*
  No
  Yes
- Coronary angioplasty / stents*
  No
  Yes
- Rheumatic fever*
  No
  Yes
- Stroke*
  No
  Yes
- Transient Ischaemic Attack (TIA)*
  No
  Yes
- Irregular Heart Rate/AF*
  No
  Yes
- Asthma*
  No
  Yes
- Tuberculosis*
  No
  Yes
- Emphysema/Bronchitis*
  No
  Yes
- Persistent cough*
  No
  Yes
- Shortness of breath*
  No
  Yes
- Obstructive sleep apnoea*
  No
  Yes
- Anaemia*
  No
  Yes
- Bleeding disorder*
  No
  Yes
- Blood clots*
  No
  Yes
- Blood transfusion*
  No
  Yes
- Hepatitis/HIV*
  No
  Yes
- Kidney disease*
  No
  Yes
- Diabetes*
  No
  Yes
If Yes
- Type
  T1
  T2
If you have diabetes are you...
- ...taking insulin?
  No
  Yes
- ...taking tablets?
  No
  Yes
- ...diet controlled?
  No
  Yes
- Disease of muscles or nerves*
  No
  Yes
- Malignant hyperthermia*
  No
  Yes
- Epilepsy*
  No
  Yes
- Blackouts/fainting*
  No
  Yes
- Medicines for long term pain*
  No
  Yes
- Recreational drugs*
  No
  Yes
- Steroids*
  No
  Yes
- Joint implants*
  No
  Yes
- Mobility aids*
  No
  Yes
- Arthritis*
  No
  Yes
- Glasses*
  No
  Yes
- Contact lens*
  No
  Yes
- Hearing aid*
  No
  Yes
- Piercings*
  No
  Yes
- ...If yes, Location
- Current smoker?*
  No
  Yes
- ...If yes, how many daily?
- Former Smoker
  No
  Yes
- Never Smoked
  No
  Yes
- Do you drink alcohol?*
  No
  Yes
- ...If yes, how much daily?
- Allergies:
  If yes, please list them here including any reactions (eg. latex, iodine, sticking plaster, antibiotics, specified foods)
- Do you have any special dietary requirements?*
  No
  Yes
- If so please list them here
- Do you currently have any skin rashes, broken skin or a skin infection?*
  No
  Yes
- Have you had an anaesthetic before?*
  No
  Yes
- General Anaesthetic*
  No
  Yes
- Spinal / Epidural*
  No
  Yes
- Any problems during or after anaesthesia?*
  No
  Yes
- ...If yes, Please specify
- Do you have problems opening your mouth or with neck stiffness?*
  No
  Yes
- ...If yes, Please specify
- Do you have difficulty climbing one or two flights of stairs?*
  No
  Yes
- What restricts this activity?
- Does lying flat make you breathless?*
  No
  Yes
- Do you have reflux/heartburn?*
  No
  Yes
- Are you or could you be pregnant?*
  No
  Yes
- Any capped or crowned teeth?*
  No
  Yes
- Dentures?*
  No
  Yes
- Have you been in a NZ hospital in the last 6 months / or in an overseas hospital in the last 12 months?*
  No
  Yes
If YES
- When
- Where
- How long
- Have you ever had MRSA or ESBL infection?*
  No
  Yes
- Do you work in a healthcare facility?*
  No
  Yes
- Do you suffer from any other conditions not already noted that you think we should know about?
  Please state details of any disability, physical or emotional needs, cultural or spiritual needs.
- Have you travelled to Asia within the last 12 months?*
  No
  Yes
- If YES, Where
- Your Height ( metres )
- Your Weight ( Kg )
- Please list all admissions to hospital / surgical procedures
  
  Reason for admission Hospital Year
  + add another line
  
  Please list your most recent hospital / surgical procedures (up to a maximum of 4)
- Please list all medications you are taking currently. (include any un-prescribed such as Herbal or Natural Remedies. Please also bring a list of your current medicines from your pharmacy.)
  
  Name of Drug Dose Frequency
  + add another line
Files
- File Size
  
  Select the files you would like to upload (you can hold the CTRL or SHIFT key to select multiple files)
You have completed all the information for your admission, please choose one of the options below.
Please note that our website does not store your personal health information on submission of this form for privacy purposes.

Review my answers Submit to Grace Hospital

	Text
	Email
	Phone ( morning )
	Phone ( afternoon )
	Phone ( evening )

	Internet Banking
	Credit Card
	Cash or EFTpos Payment

	No
	Yes

	No
	Yes

	No
	Yes

Internet Banking Details

Patient Declaration

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