Registration Form - Dr Amelia Boucher

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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*

Do you consent to receiving a copy of Dr Boucher's letter by email?*

Yes

No (I prefer to receive by post)

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:*

As a routine we write back to the Referring Doctor after your consultation. Please indicate if you would also like your GP to receive a copy of all correspondence*

Yes

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 problem for which you are seeking help from Dr Boucher? (Not compulsory to answer)

List all 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 now 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 Hepatitis?*

Yes

If 'Yes', 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:*

The practice of Plastic Surgery involves the examination of the skin. You may be asked to remove some of your clothing. A chaperone will always be available on request.

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.