• Braemar Pre-Admission Form
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Admission Information

DD slash MM slash YYYY
Time of admission
:
Nothing to eat from
:
Nothing to drink from
:

Personal Details

DD slash MM slash YYYY
Are you a permanent NZ resident?(Required)
Home Address(Required)
Postal Address (if different to home)
Email Invoice?(Required)

Next of Kin

Home Address(Required)

Contact Person (if different from above)

Home Address

Additional Information

Have you been treated in this hospital previously?(Required)
Do you require “Boarder” accomodation for an adult with a child patient?(Required)

If your child is 12 years of age and under one parent may stay free of charge. If your child is 13 years of age and over, there is a $100 charge for one parent to stay the night. This charge may be covered by your insurance policy

Braemar Hospital is unable to accept any responsibility for loss or damage to valuables or money belonging to patients.

Health Information

Please answer all health questions

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

Yes

No

Yes

No

High blood pressure controlled with medication(Required)
Heart attack(Required)
Heart murmur(Required)
Artificial heart valve(Required)
Chest pains / Angina(Required)
Coronary angiogram or stents in heart(Required)
Rheumatic Fever(Required)
Atrial Fibrillation / Palpitations / Arrythmias(Required)
Cardiac devices eg: pacemaker, ICD(Required)
COPD / Emphysema(Required)
Asthma(Required)
Have you had a head cold, throat / chest infection in the last 4 weeks?(Required)
Persistent cough / croup(Required)
Shortness of breath(Required)
Severe snoring(Required)
Obstructive Sleep Apnoea(Required)
Covid 19(Required)
Stroke / TIA(Required)
Anaemia / Bleeding disorders(Required)
Blood clots in legs or lungs (DVT / PE)(Required)
Family history of blood clots(Required)
In the last 6 weeks have you been on a long distance flight?(Required)
Epilepsy / Seizure(Required)
Blackouts / Fainting(Required)
Migraines / Severe headaches(Required)
Heartburn/Reflux(Required)
Diabetes: Type 1(Required)
Diabetes: Type 2(Required)
Thyroid problems(Required)
Kidney problems(Required)
Hepatitis(Required)
Cirrhosis(Required)
HIV / AIDS(Required)
Tuberculosis(Required)
Mental illness(Required)
Anxiety(Required)
Post-Traumatic Stress Disorder (PTSD)(Required)
Depression(Required)
Dementia / Alzheimer’s(Required)
Arthritis(Required)
Joint implants or metal ware(Required)
Have you had any falls in the last 6 months?(Required)
Is your activity currently restricted by pain?(Required)
Bowel conditions(Required)
Bladder conditions including current / recent urine infection(Required)
Current skin problems eg: ulcers, wounds, eczema, boils, pressure areas(Required)
Do you currently use:
Crutches / Walking stick(Required)
Walker / Frame(Required)
Wheelchair(Required)
Have you suffered post op nausea and vomiting with recent surgeries?(Required)
Do you experience motion sickness?(Required)
Have you or a blood relative ever had any problems during or after anaesthesia? eg: Malignant Hyperthermia, Muscular Dystrophy(Required)
Can you easily climb 1 flight of stairs?(Required)
Can you easily climb 2 flights of stairs?(Required)
Difficulty opening your mouth?(Required)
Are you, or could you be pregnant?(Required)
Do you currently smoke or vape?(Required)
Have you previously smoked or vaped regularly?(Required)
Do you drink alcohol?(Required)
Do you use recreational drugs?(Required)
Do you wear glasses / contact lenses?(Required)
Do you have any other eye conditions?(Required)
Do you have hearing difficulties?(Required)
Any special dietary requirements?(Required)
Do you have a disability?(Required)
If your surgery requires the removal of body parts, would you like them returned to you if possible?(Required)
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)
Have you travelled overseas (without healthcare contact) to the Indian sub-continent OR South-East Asian country in the last 12 months?(Required)
Have you worked in an overseas or NZ hospital in the last 12 months?(Required)
Have you been admitted overnight to a New Zealand hospital or hospital level residential care in the last 12 months?(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)
Are you under medical specialist care eg: cardiologist, oncologist, rheumatologist?(Required)
Do you currently live alone?(Required)
Do you have any religious or spiritual beliefs / practices or cultural needs we should be aware of?(Required)
Do you have difficulty understanding English?(Required)
Is there anything we need to know that you prefer not to write on this questionnaire?(Required)
If YES, we will contact you prior to your admission.

DO NOT leave this blank. If you do not know, please provide an estimate.

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

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)
DD slash MM slash YYYY

have read and accept the above terms.