This form will send to: Hamilton Hospital     

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Patient Admission Form


PERSONAL AND ADMINISTRATION DETAILS

Tick the box or boxes which apply to you.

NEXT OF KIN/CONTACT PERSON

PAYMENT DETAILS
How will your procedure be paid for? Tick and complete as many as applies:
Details of health insurance
(Bring your prior approval letter)

Additional charges
Depending on your health insurance policy or plan you may be required to pay an excess (co-payment).
You may also be required to pay for some charges such as visitor meals that are not covered by insurance, ACC or DHB.

Payment prior to surgery
You may be asked to pay a deposit 3-5 days before admission. The amount is based on the estimated cost of the procedure payable by you not otherwise covered by your insurance, ACC or DHB. The deposit will be refunded to you if the procedure is cancelled.

Methods of payment
We accept payment by EFTPOS, VISA, Mastercard, internet banking or online at our website www.southerncrosshospitals.co.nz (search "payment information"). Personal cheques are not accepted. We also prefer not to receive payment by cash.

Internet banking details
Payee: Southern Cross Hospitals Ltd Bank a/c: 12-3113-0126623-00
Particulars: Patient Name Code: Date of Surgery e.g. 12 Sep 2020 Reference: Hospital e.g. Hamilton

Would you like to receive your invoice via email?
We will send the invoice to the email address you have provided above. If you wish it to go to another email address, please provide it here:
(if different from the one provided above):
AGREEMENT

I agree to settle my Hospital account in full at the time of my discharge when personally paying my account or where I do not have "prior approval" from my insurer. I understand I am responsible for any outstanding balance if my procedure is not fully covered by insurance, ACC or other contract.

I give permission to Southern Cross Hospitals or any health professional (such as my medical specialist) involved in my care in relation to this admission to Hospital, to access health information about me that is relevant to my treatment (including pre-admission and after discharge), which may be held by Southern Cross Hospitals, other health professionals or other health organisations.

I give permission to Southern Cross Hospitals or any health professional involved in my care for this admission to Hospital, to access health information about me that is relevant to my current treatment, which may be held by Southern Cross Hospitals, other health professionals or other health organisations. I understand that other clinical team members such as student nurses and qualified medical trainees may have supervised involvement with my care and that I have the right to decline their presence or contribution to my care delivery.

I understand the admitting Surgeon, Anaesthetist and other Doctors or health professionals using Southern Cross Hospitals facilities are independent and not employees of Southern Cross Hospitals, with respect to both my treatment, care and account payment. I accept that this agreement is covered by New Zealand law. The details above have been completed by:

(To be signed at the hospital upon admission)

Patient Health Questionnaire


Please complete this questionnaire carefully as the information you supply helps us to provide you with the best and safest possible care during your stay at our hospital. The questionnaire has four sections:

A Your general health

B In preparation for your hospital admission

C In preparation for your procedure

D Your current medicines

All questions in this questionnaire are about the person being treated at the hospital (the patient). If you are filling this out for the patient, only provide information relating to the patient’s health.

Section A: Your General Health

A1 MEDICAL PROCEDURE HEALTH ALERTS
Do any of the following apply to you?
Q Yes No
1 Difficulty climbing more than a flight of stairs
2 Motion sickness
3 Jaw problems (difficulty opening mouth)
4 Problems with a previous anaesthetic
5 Family history of problems with an anaesthetic
6 Pacemaker or heart valve replacement
7 Joint implants
8 Other implant or prostheses and metalware
9 Substance use or dependency
10 Former smoker
11 Currently on smoking cessation treatment
12 Current smoker
13 Vaping
14 Pregnant or possibly pregnant
15 Breastfeeding
16 MedicAlert bracelet or necklace wearer
NOTE: If you answer YES to any of the following questions (17 - 46), please use the box beneath Question 46 to provide information, including the question number.
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
- If Yes, please specify and provide details of any recent treatment in the Comments box below
46
- If Yes, please specify in the Comments box below
RE QUESTION YOUR COMMENT
21. GP says my blood pressure is slightly high, but I am not taking any medicine. ----Example----

Section B: In Preparation For Your Hospital Admission

B1 YOUR ALLERGIES, SENSITIVITIES, OR INTOLERANCES
Q Yes No
47
48
- If Yes, please specify and describe the reaction using the box below
Item Reaction
Skin-related
Medicine-related
Food-related
Other
B2 YOUR NEEDS AND PREFERENCES
Please answer these questions to help us to tailor how we care for you.
If you answer Yes to any of these questions, we may contact you to discuss your specific needs.
Q Yes No
49
50
51
52
53
54
55

56 Do you have any specific food dislikes?
For allergies or intolerances, refer to question 48

Section C: In Preparation For Your Procedure

C1 MEDICAL PROCEDURE HISTORY
Height
Weight
Q Yes No
57
- if Yes, please outline your previous admissions in the table below.
Procedure or event Year Hospital
C2. ANAESTHESIA CONSIDERATIONS
Q Yes No
58
59
60
C3. PERSONAL ITEMS
Do you use any of these personal items?
Q Yes No
61
62
63
-If Yes above, use this space to provide details, if needed, using the question number(s) for reference.
C4. BLOOD CLOT AND INFECTION CONSIDERATIONS
Q Yes No
64 Have you completed the pre-admission risk assessment in the brochure?
65 -If Yes, when?
66
67
68
69
-If Yes, please specify the country:
70
-If Yes, please specify the country:
71
-If Yes, please specify:
72
-If Yes, please specify:
C5. OTHER CONCERNS
Q Yes No
73
-If Yes, please discuss with your nurse or medical specialist when you arrive at the hospital
74
- if Yes, who would you like to speak with?

Section D: Your Current Medicines

For your safety, it is extremely important that your doctor and nurses know precisely which medicines you are currently using.

Important instructions.

  1. List below all medicines you currently use, and bring them with you to the hospital in their original containers
  2. If you are taking any blood thinning medication or supplements, check with your surgeon if these need to be stopped prior to your admission.
  3. If you have a medication card or printout from your GP or pharmacist, please bring it with you to the hospital, as well as completing the list below.


MEDICINE REMINDERS
Which of the examples below apply to you?
There are many types of medicine Medicines come in many forms Medicines are taken for many common conditions
prescription medicines
herbal medicines
natural medicines
homeopathic medicines
over-the-counter-medicines
vitamins
supplements
contraceptives
steroids
tablets
capsules
inhalers
drops
syrups
patches
suppositories
creams
injections
other liquids
heart disease
high blood pressure
blood thinning
dietary deficiencies
emotional conditions
infections
diabetes
sleeplessness
epilepsy
D1. YOUR CURRENT MEDICINES HOSPITAL USE ONLY
Patient to complete - list all medicines you currently use. Reconciled: Yes () | No (x) | Not available (NA)
Name of medicine Strength How much you use, and when Medicine container Medication card Patient or whanau/family Other(state) eg, 'phoned GP' ON ADMISSION: Date/time last taken
sp. Paracetamol     --example-- 500mg 2 capsules every 6 hours - - - - -
Comment if No:

         
Comment if No:

         
Comment if No:

         
Comment if No:

         
Comment if No:

Name of medicine Strength How much you use, and when Medicine container Medication card Patient or whanau/family Other(state) eg, 'phoned GP' ON ADMISSION: Date/time last taken
         
Comment if No:

         
Comment if No:

         
Comment if No:

         
Comment if No:

         
Comment if No:

         
Comment if No:

         
Comment if No:

         
Comment if No:

         
Comment if No:

         
Comment if No:

         
Comment if No:

Please provide any additional comments in the space below with the question number for reference if appropriate:

     This form will send to: Hamilton Hospital