Sample page - SkinDoctor Aesthetics

First Name *

Last Name *

Mobile Phone *

Email Address *

Date of Birth *

Gender *FemaleMaleGender Diverse

Emergency Contact (Next of Kin) *

Relationship (Next of Kin) *

Phone Number (Next of Kin) *

Street Address *

Suburb *

City *

Postcode *

Is the patient 16 and over? *YesNo

Authority Name *

Authority Relationship *

Authority Phone *

Authority Basis (Parent/Guardian)*

I am currently registered as a patient with another GP in NZ *YesNo

Doctor or Practice Name *

Address / Location *-

Please upload a copy of your valid ID document. e.g. Passport, Drivers License, Birth Cert etc.

NB. Parent or Caregiver to sign if you are under 16 years

I acknowledge that I have reviewed the relevant fee displayed/provided to me for services at SkinDoctor.
I acknowledge to pay all fees due to the practice for all consultations, services rendered, and any applicable fees advised at the time of my appointment or request for services.
I acknowledge once work/service has been undertaken at my request by the practice I am liable to complete full payment for the services rendered.
I acknowledge any payment not completed within 7 days from service rendered at the will incur an additional $15.00 administration fee and an additional $5 per month will incur a late penalty fee.
I acknowledge if unpaid after 30 days from the date of service, my account will be transferred to a debt collection agency and all costs associated with this will be my responsibility to pay directly to the debt collection agency.

I acknowledge the above Terms of Trade *

Your Signature:

Date *