New Patient Intake Form Template for New Zealand

A comprehensive medical and administrative document used in New Zealand healthcare settings to collect essential information from new patients. This form complies with New Zealand healthcare regulations, including the Health Information Privacy Code 2020 and the Code of Health and Disability Services Consumers' Rights. It captures patient demographic information, medical history, emergency contacts, insurance details, and necessary consents while ensuring privacy protection and informed consent requirements are met under New Zealand law.

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What is a New Patient Intake Form?

The New Patient Intake Form is a fundamental document used across healthcare providers in New Zealand when registering new patients. This document serves as the initial point of contact between a healthcare provider and a patient, collecting crucial medical, personal, and administrative information necessary for providing appropriate care. The form must comply with New Zealand's healthcare regulations, including the Health Information Privacy Code 2020, the Privacy Act 2020, and the Code of Health and Disability Services Consumers' Rights. It is designed to capture comprehensive patient information while ensuring proper informed consent and privacy protection. The form is typically used during a patient's first visit to a new healthcare provider and forms part of their ongoing medical record.

What sections should be included in a New Patient Intake Form?

1. Patient Personal Information: Basic demographic information including full name, date of birth, contact details, and NHI number

2. Emergency Contact Details: Contact information for next of kin or emergency contacts

3. Insurance and Payment Information: Health insurance details, ACC information, and preferred payment methods

4. Medical History: Current health conditions, past surgeries, hospitalizations, and chronic conditions

5. Current Medications: List of current medications, dosages, and supplements

6. Allergies and Reactions: Known allergies to medications, foods, or environmental factors

7. Family Medical History: Relevant family health conditions and genetic predispositions

8. Privacy Statement: Information about how patient data will be collected, used, and protected as per Privacy Act 2020

9. Patient Rights and Responsibilities: Statement of patient rights under the Code of Health and Disability Services Consumers' Rights

10. Consent for Treatment: General consent for medical treatment and information sharing with other healthcare providers

What sections are optional to include in a New Patient Intake Form?

1. Cultural Considerations: Section for recording cultural preferences and requirements, particularly relevant for Māori patients

2. Language Preferences: For patients requiring interpreter services or preferring communications in languages other than English

3. Advance Care Directives: Optional section for patients who wish to record their advance care preferences

4. Mental Health History: Detailed mental health history section for practices with mental health focus

5. Women's Health History: Specific section for female patients including reproductive health history

6. Alternative Medicine Use: Section for recording use of traditional or alternative medicines and treatments

What schedules should be included in a New Patient Intake Form?

1. Medical History Questionnaire: Detailed questionnaire about specific medical conditions and history

2. Vaccination Record: Schedule for recording patient's vaccination history and future requirements

3. Privacy Policy: Detailed privacy policy document as required by NZ Privacy Act 2020

4. Practice Information Sheet: Information about practice hours, fees, and services

5. Patient Rights Brochure: Detailed information about patient rights and complaint procedures

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok��˰� | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents

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Free to use

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Simple Intake Form

A New Zealand-compliant intake form for collecting and managing client information, structured according to NZ privacy laws and business requirements.

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Generate a Bespoke Document

Download a Standard New Patient Intake Form

Review your own New Patient Intake Form

What is a New Patient Intake Form?

What sections should be included in a New Patient Intake Form?

What sections are optional to include in a New Patient Intake Form?

What schedules should be included in a New Patient Intake Form?

Authors

Alex Denne

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