Braemar Pre-Admission Form

Please complete this form prior to your admission to Braemar Hospital. This form helps us find out everything we need to know before your admission.

Please allow around 10-15 minutes to complete the form. Please have your medical insurance approval number or ACC approval number handy. If you have any questions or need help completing this form, please contact Braemar Hospital on 07 843 1899.

A copy of the form will be sent to the Braemar Pre-Admission team. The Pre-Admission team may contact you prior to your admission to discuss your responses.

Admission Information

Date of admission(Required)

Time of admission

Nothing to eat from

Nothing to drink from

Procedure(Required)

Personal Details

Legal Surname(Required)

Title

Legal First Names(Required)

Preferred Name

Date of Birth(Required)

Country of Birth(Required)

Gender/Pronouns(Required)

Are you a permanent NZ resident?(Required)

Yes

Ethnicity(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address (if different to home)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone 1(Required)

Phone 2

Email(Required)

Email Invoice?(Required)

Yes

Surgeon or Specialist

GP's Name(Required)

Practice(Required)

Next of Kin

Name(Required)

Relationship(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone Number(Required)

Contact Person (if different from above)

Name

Relationship

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone Number

Additional Information

Medical Insurance Company

Approval Number

ACC Approval Number

Have you been treated in this hospital previously?(Required)

Yes

Name previously used

Do you require “Boarder” accomodation for an adult with a child patient?(Required)

Yes

Health Information

Please answer all health questions

Do you have, or have you ever had, any of the following?

Yes

High blood pressure controlled with medication(Required)

Yes

Heart attack(Required)

Yes

Heart murmur(Required)

Yes

Artificial heart valve(Required)

Yes

Chest pains / Angina(Required)

Yes

Coronary angiogram or stents in heart(Required)

Yes

Rheumatic Fever(Required)

Yes

Atrial Fibrillation / Palpitations / Arrythmias(Required)

Yes

Cardiac devices eg: pacemaker, ICD(Required)

Yes

COPD / Emphysema(Required)

Yes

Asthma(Required)

Yes

Have you had a head cold, throat / chest infection in the last 4 weeks?(Required)

Yes

Persistent cough / croup(Required)

Yes

Shortness of breath(Required)

Yes

Severe snoring(Required)

Yes

Obstructive Sleep Apnoea(Required)

Yes

Covid 19(Required)

Yes

Stroke / TIA(Required)

Yes

Anaemia / Bleeding disorders(Required)

Yes

Blood clots in legs or lungs (DVT / PE)(Required)

Yes

Family history of blood clots(Required)

Yes

In the last 6 weeks have you been on a long distance flight?(Required)

Yes

Epilepsy / Seizure(Required)

Yes

Blackouts / Fainting(Required)

Yes

Migraines / Severe headaches(Required)

Yes

Heartburn/Reflux(Required)

Yes

Diabetes: Type 1(Required)

Yes

Diabetes: Type 2(Required)

Yes

Thyroid problems(Required)

Yes

Kidney problems(Required)

Yes

Hepatitis(Required)

Yes

Cirrhosis(Required)

Yes

HIV / AIDS(Required)

Yes

Tuberculosis(Required)

Yes

Mental illness(Required)

Yes

Anxiety(Required)

Yes

Post-Traumatic Stress Disorder (PTSD)(Required)

Yes

Depression(Required)

Yes

Dementia / Alzheimer’s(Required)

Yes

Arthritis(Required)

Yes

Joint implants or metal ware(Required)

Yes

Have you had any falls in the last 6 months?(Required)

Yes

Is your activity currently restricted by pain?(Required)

Yes

Bowel conditions(Required)

Yes

Bladder conditions including current / recent urine infection(Required)

Yes

Current skin problems eg: ulcers, wounds, eczema, boils, pressure areas(Required)

Yes

Do you currently use:

Crutches / Walking stick(Required)

Yes

Walker / Frame(Required)

Yes

Wheelchair(Required)

Yes

Have you suffered post op nausea and vomiting with recent surgeries?(Required)

Yes

Do you experience motion sickness?(Required)

Yes

Have you or a blood relative ever had any problems during or after anaesthesia? eg: Malignant Hyperthermia, Muscular Dystrophy(Required)

Yes

Can you easily climb 1 flight of stairs?(Required)

Yes

Can you easily climb 2 flights of stairs?(Required)

Yes

Difficulty opening your mouth?(Required)

Yes

Are you, or could you be pregnant?(Required)

Yes

Do you currently smoke or vape?(Required)

Yes

Have you previously smoked or vaped regularly?(Required)

Yes

When did you give up?(Required)

Do you drink alcohol?(Required)

Yes

How many units weekly (1 standard glass wine or 1/2 glass beer = 1 unit)(Required)

Do you use recreational drugs?(Required)

Yes

What do you use?(Required)

How often do you use?(Required)

Do you wear glasses / contact lenses?(Required)

Yes

Do you have any other eye conditions?(Required)

Yes

Do you have hearing difficulties?(Required)

Yes

Any special dietary requirements?(Required)

Yes

Do you have a disability?(Required)

Yes

If your surgery requires the removal of body parts, would you like them returned to you if possible?(Required)

Yes

If you answered YES to any of the questions above, please provide details, including treatment.

Have you had previous surgery? If YES, please provide details.

Have you been admitted overnight or had any dental, dialysis, endoscopy or oncology procedures in an overseas healthcare facility in the last 12 months?(Required)

Yes

Have you travelled overseas (without healthcare contact) to a South Asian OR South-East Asian country in the last 12 months?(Required)

Yes

Have you worked in an overseas or NZ hospital in the last 12 months?(Required)

Yes

Have you been admitted overnight to a New Zealand hospital or hospital level residential care in the last 12 months?(Required)

Yes

If YES, please provide details(Required)

Do you have any other medical conditions not already covered, or is there anything else we should know about you eg: Parkinson’s, muscle nerve disease, currently breastfeeding, etc?(Required)

Yes

If YES, please provide details(Required)

Are you under medical specialist care eg: cardiologist, oncologist, rheumatologist?(Required)

Yes

If YES, please provide details(Required)

When did you last see them(Required)

Do you currently live alone?(Required)

Yes

If YES, who is going to support and care for you on discharge?(Required)

Do you have any religious or spiritual beliefs / practices or cultural needs we should be aware of?(Required)

Yes

If YES, please provide details(Required)

Do you have difficulty understanding English?(Required)

Yes

If YES, what is your preferred language(Required)

Is there anything we need to know that you prefer not to write on this questionnaire?(Required)

Yes

If YES, we will contact you prior to your admission.

Height(Required)

Weight(Required)

Have you ever had an allergic reaction or an adverse reaction to any drugs, iodine, sticking plaster, food etc?(Required)

Yes

Substance

Reaction

Do you take any medicines – tablets, inhalers, patches etc prescribed by your doctor or over the counter (Include any herbal or natural remedies).(Required)

Yes

Please list ALL medicines – tablets, inhalers, patches etc prescribed by your doctor or over the counter (Include any herbal or natural remedies).(Required)

Name of medication

Dose

Frequency

Privacy Statement

We collect your health information to provide you with appropriate care and to monitor quality.

We share this information with other health care providers and agencies involved in your care.

We treat your information as confidential and ensure that it is kept secure and only accessed by authorised persons.

You have the right to request access to your records and to request correction of the information. Information may be supplied to family, support people or other agencies if you give us your permission or disclosure is authorised by law.

Our full Privacy Statement is available on our website or from the hospital reception.

Privacy Statement(Required)

I have read and understood this statement.

Account Information

Statement to be signed by patient before surgery.

I understand and agree that:

Unless my specialist has advised me otherwise, any hospital fee figure given to me is an estimate only. For example, a procedure may take a shorter or longer time to complete, or, you may require a longer stay in hospital than originally estimated. In most cases though your specialist will be able to provide you with a reasonably accurate estimate.
I am responsible for the payment of all costs associated with my stay at Braemar Hospital (excluding those which are paid for by another organisation such as ACC, an insurance company, a district health board etc).
If I am an ACC patient, I will be invoiced for costs not paid by ACC, such as telephone calls, room upgrades, extra meals etc.

Before the procedure:

I give permission for Braemar Hospital to check on my current credit status before (or after) my procedure.
If I have no insurance cover or no prior approval from my insurance company, Braemar Hospital may reserve the right to insist that I pay an estimate of the cost of my procedure in advance. (Braemar Hospital recommends that you obtain prior approval from your insurance company).

Invoice and payment:

Unless another organisation such as ACC or a district health board are paying the full amount, I will receive invoices from:

Braemar Hospital, the specialist, the anaesthetist (where applicable), and any other services such as physiotherapy (where applicable).

If I have insurance cover for my procedure, I agree to promptly:

Send the invoice to the insurance company.
Braemar Hospital making the claim on my behalf for the hospital costs directly with my insurance provider where possible
Pay for all of the cost of the procedure that is not paid by my insurance company.

If I do not have insurance cover:

I will pay the account in full promptly on receipt of invoice.

Overdue accounts:

I agree that I have sufficient funds in place to meet the costs of my procedure at Braemar Hospital on the due date.

If I do not pay on the due date:

I will pay the interest charged by Braemar Hospital on any amount unpaid after the due date.
The interest rate will be 1% per month of the amount unpaid at the end of each month.
Braemar Hospital may instruct their debt collector or solicitor to recover any amount unpaid after the due date.
I will pay for all of the debt collection costs incurred by Braemar Hospital or their debt collector and/or legal costs on a solicitor/client basis

I(Required)

Patient

Parent

Caregiver

Your Full Name(Required)

Date(Required)

have read and accept the above terms.

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