Registration Form - Dr Carl Eagleton

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Please complete ALL fields marked with an asterisk *

Full Name of Patient*

Title First Name(s) Surname

Name you prefer to be known by

Sex*

Male

Female

Other

Date of Birth*

NHI number (if known)

Physical Address*

Number / Street Address Suburb City Postal Code Country

Is your Postal Address the same as your Physical Address?

Yes

Postal Address (If different from above)

Address Line 1 Address Line 2 City Postal Code Country

Home Phone

Work Phone

Mobile Phone

E-mail

Enter Email Confirm Email

Preferred method of contact*

Country of birth*

Occupation*

Health Insurance

Does your consultation involve Health Insurance cover?*

Yes

Unsure

Insurance Company*

Policy Type (if known - eg. Ultracare, Surgery only etc)

Policy/Membership Number

ACC eligible claims

Does your consultation involve an existing ACC eligible claim?*

Yes

Unsure

ACC Claim Number*

Date of injury*

GP / Referring Doctor details

Do you have a regular Family Doctor (GP)?*

Yes

Name of GP:*

Practice Name:*

Practice Address:

Is your GP the Referring Doctor?*

Yes

I am self-referring

Source of your referral:*

Doctor

Self

Name of Referring Doctor:*

How did you hear about us?

Emergency Contact Details:

Name*

Relationship*

Address:*

Contact Phone:*

Health Questions

Have you ever smoked regularly?*

Yes, currently

Yes, but I've quit

Number of cigarettes smoked per day:*

Total years smoked, and year you quit:*

Are you currently pregnant?*

Yes

Unsure

What is the medical problem for which you are seeking help from Dr Eagleton? (Not compulsory to answer)

List all previous surgeries, with approximate dates e.g. tonsils, hernia, cosmetic:*

Enter 'Nil' - if no surgical history

List all medical problems or major illnesses you have had:*

Enter 'Nil' - if no medical history

List all medications you are currently taking (including aspirin, vitamins, prescription or over-the-counter medications)*

Enter 'Nil' if on no regular medication

List any allergies or sensitivities e.g. Sulphur drugs, Penicillin, Elastoplast, Codeine etc.*

Enter 'Nil' - if no allergies or sensitivities

Have you ever had any problems with anaesthesia?*

Yes

Never previously had an anaesthetic

Details of previous anaesthetic problem:*

Do you, or anybody in your family have a history of bleeding disorders?*

Yes

Details of bleeding disorder:*

Do you take Vitamin E, Aspirin, Warfarin, non-steroidal anti-inflammatory or other medications, which can “thin” the blood or increase blood clotting time?*

Yes

Name of medication(s):*

Have you ever had a blood transfusion?*

Yes

Year(s) of blood transfusion(s):*

Have you ever had any of the following?

Heart problems (including Rheumatic Fever)*

Yes

Ankle swelling*

Yes

Faints / 'Turns' / Stroke*

Yes

Elevated Blood Pressure (requiring medication)*

Yes

Chest pain*

Yes

Tuberculosis (TB)*

Yes

Asthma*

Yes

Pneumonia*

Yes

Persistent cough*

Yes

HIV/AIDS*

Yes

Diabetes*

Yes

What type of Diabetes do you have?*

Type 1

Type 2

Other

Epilepsy / 'Fits'*

Yes

Hepatitis*

Yes

Any infectious diseases*

Yes

If 'Yes' to any of the above, please provide details:*

Terms and Conditions:

Please tick how you will be settling your account. Payment is expected on the day of consultation, unless otherwise arranged.

Payment method:*

Please Note: American Express is not accepted

Name of Person completing this form (must be over 16 years):*

Are you the Patient?*

Yes

Relationship to the Patient:

Date*

Privacy Statement. Please read before submitting this form.

Privacy Summary & Consent - Collection & Use: We collect personal and health information (including your medical history and NHI) to provide you with safe specialist care. While we usually collect this from you, under IPP3A we may also receive information from third parties (such as GP referral letters, hospital discharge summaries, and lab/X-ray results) to ensure a complete clinical picture. Disclosure: We share relevant information with other healthcare providers involved in your treatment (e.g., your GP, anaesthetists, or hospitals) and, where applicable, with ACC, your health insurer, or Te Whatu Ora for billing and audit purposes. Security & Rights: Your data is stored securely in accordance with the Health Information Privacy Code 2020. You have the right to access and request corrections to your information at any time. Our full Privacy Statement is available at https://www.marinaspecialists.co.nz/privacy-statement/ or at Reception.