Home
Our Team
Breast Health
Breast Tests
Breast Cancer
Breast Surgery
FAQS
Referrals
Register
Contact Us

Patient Registration

Healthcare Interpreter Service


At Breast Associates we recognise cultural diversity in New Zealand. Ensuring that you are fully informed we offer a comprehensive private interpreting service. If you would like an interpreter for any of your consultations please let us know so that we can book an interpreter for you, or you are welcome to book your own directly. The following services are available to you:

SINT – Onsite (Face to Face) interpreting service
This service provides you with a language interpreter to be present at your consultation to assist you to facilitate communication between you and your specialist.

TINT – Telephone (Conference Call) interpreting service
This service provides you with a language interpreter to facilitate communication between two or more people. It is most cost-effective but may not be appropriate in certain circumstances.

Document Translations
This service provides you with qualified translation of written information, e.g. brochures, reports, etc.

Breast Associates uses a private interpreting service - please contact reception if you would like the details of this service. There is an extra fee to access these services and this is payable at the time of consultation.

 

Patient Registration
To make your visit smoother and more efficient, please fill the form below before the date of your consultation. 

Your legal name *
Your preferred name (if different from above)
Title *
Your date of birth *
Your phone number *
Address line 1 *
Address line 2
City *
Postal Code *
Email address *
NHI number if known
Name of next of Kin *
Relationship of your next of Kin *
Next of Kin phone number *
How did you hear about us? *
If you selected other, how did you hear about us?
Name of referring doctor and practice
Name of GP if different to above
Your occupation *
Your ethnic group *
Medical Insurance Provider and Policy Number *
Correspondence may be sent to me by email/text *
Are you entitled to free hospital care in New Zealand? *
Do you have any cultural needs?
What problem are you seeing the doctor about? *
How long have you had this? *
When was your last mammogram? Where was it done? *
Previous breast surgery? If so, when?
Family history of cancer? Please state relationship, type of cancer and age of diagnosis.
Have you had any children? What ages are they? Did you breastfeed?
Date of last menstrual period? Or have you had a hysterectomy? *
Please list all medications including herbal remedies, HRT & contraceptives.
Any allergies to medication? Any other allergies? Please give details.
Do you smoke? *
If YES, how many per week?
Do you drink alcohol? *
If YES, how many per week?

Do you have, or have you ever had…

Heart problems *
Asthma *
Hepatitis *
HIV Positive *
Stroke / TIA *
Rheumatic Fever *
Epilepsy *
High Blood Pressure *
Diabetes *
Clots in Legs or Lungs *
When you sustain a cut do you stop bleeding normally? *
Have you had any problems with anaesthetics? *

 

Consent

All personal information collected by Breast Associates is treated with respect and remains confidential. Breast Associates may request or share your information with other Clinicians involved in your care, or use your unidentifiable data for audit or scientific purposes. Any third party invoices (e.g. laboratory fees) may be passed on to the patent for payment. A chaperone is available on request. If there are any questions that do not apply please leave it blank.

 

 

 

CONTACT US

Breast Associates | Ascot Central, 7 Ellerslie Racecourse Drive, Greenlane, Auckland, New Zealand.

 
Ph +64 9 522 1346 | info@breastassociates.co.nz

Privacy Policy
© Copyright 2016. Breast Associates. All Rights Reserved. Site designed by Spruik.