Patient Registration "*" indicates required fields If you are a new patient, please fill in this form to register as a patient at Hamilton Eye Clinic. If you have any questions about this form, please phone us at 07 834 0006 and we'll be happy to assist you. Which specialist would you like to see?*Please SelectDr Benjamin HoyDr Bheema PatilDr David WorsleyDr James McKelvieDr John DicksonDr Michael MerrimanDr Rohan WeerekoonDr Selma MatloobDr Stephen GuestDr Stephen NgDr Ammar Bin SadiqDr Thiyaga KrishnanDr Verona BothaI don't know Your DetailsTitle*Please SelectMrMrsMsMissDrOtherFirst Name(s)* Surname* Second/Third Names Previous Name(s) Gender*Please SelectMaleFemaleDate of Birth* DD slash MM slash YYYY Ethnicity* Are you a New Zealand resident?* Yes No NHI Number (If Known) Residential Address* Postal Address* Same as above Different Postal Address Postal Address* Primary Phone Number* Phone (Mobile)* Same As Primary Phone Number Other Phone (Home) Same As Primary Phone Number Other Phone (Work) Email Next of Kin DetailsNext of Kin* Relationship* Phone Number* Email Address Health DetailsHealth Insurer Membership Number ACC Number Family Doctors (GP) Practice Optometrist Optometrist Clinic Health ConditionsBlood Clots* Yes No Anaesthetic Problems* Yes No Diabetes* Yes No Anxiety Disorder* Yes No Insulin* Yes No Stroke* Yes No High Blood Pressure* Yes No Stomach Ulcer* Yes No Heart Condition, Angina* Yes No MRSA (Golden Staph)* Yes No Heart Murmur* Yes No Hepatitis* Yes No Smoking* Yes No Exposure to HIV/AIDS* Yes No Asthma* Yes No Poor Hearing* Yes No Bleeding Problems* Yes No Epilepsy* Yes No Migraine* Yes No Are you taking Asprin?* Yes No Are you taking Warfarin?* Yes No Cancer* Yes No Please specify type of cancer* Allergies* Yes No Please state your allergies* Do you have any other serious illness or major condition? (Please state)Please list all current medications that you are takingPrevious Eye Operations Approximate Date All Current Medications I give permission for Hamilton Eye Clinic to contact me by Phone* Yes No I give permission for Hamilton Eye Clinic to contact me by Email* Yes No How would you like to be contacted?*Consent* By clicking submit, you agree/consent to our terms and conditions for storage of your health information.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.