Casual Patient Account Information Form

Patient Surname:

First Names:

Title:

Master

Mrs

Miss

Gender:

Male

Female

Other

Physical Address:

Billing Address:

Date of Birth:

ID-Drive's Licence/Passport details:

Ethnicity:

Phone:

Mobile:

Email:

GP (Medical Centre):

Your visit today is:

Accident

Medical

Residency Status:

Visitor to New Plymouth

Visitor to New Zealand

Student Visa

Working Visa

Resident Visa

Employer's Name:

Employer's Address:

Occupation:

Next of Kin / Emergency Contact Details

Full Name:

Date of Birth:

Physical Address:

Billing Address:

Phone:

Mobile:

Relationship to Patient:

Email:

Terms and Conditions

Definition and Payment
1. "Doctor" shall mean Medicross Taranaki Limited T/A Medicross Taranaki.
2. "Patient" shall mean the Patient or any person (or persons) that agree herein to be liable for the debts of the Patient on a principal debtor basis.
3. Time for payment for the Services shall be of the essence and will be stated on the invoice. If no time is stated, then payment shall be on delivery of the Service.
4. At the Doctor's sole discretion, payment for approved Patients or Persons responsible for the Account shall be made by instalments in accordance with the Doctor's payment schedule.
Default
1. Interest on overdue invoices shall accrue daily from the date when payment becomes due, until the date of payment, at a rate of two and a half percent (2.5%) per calendar month (and at the Doctor's sole discretion such interest shall compound monthly at such a rate) after as well as before any judgment.
2. If the Patient owes the Doctor any money the Patient shall indemnify the Doctor from and against all costs and disbursements incurred by the Doctor in recovering the debt (including but not limited to internal administration fees, legal costs on a solicitor and own client basis, the Doctor's contract default fees, and bank dishonour fees).
3. Further to any other rights or remedies the Doctor may have under this contract, if a Patient has made payment to the Doctor by credit card, and the transaction is subsequently reversed, the Patient shall be liable for the amount of the reversed transaction, in addition to any further costs incurred by the Doctor under this clause 2 where it can be proven that such reversal is found to be illegal, fraudulent or in contravention to the Patient's obligations under this agreement.
4. Without prejudice to any other remedies the Doctor may have, if at any time the Patient is in breach of any obligation (including those relating to payment) under these terms and conditions the Doctor may suspend or terminate the supply of Goods to the Patient. The Doctor will not be liable to the Patient for any loss or damage the Patient suffers because the Doctor has exercised its rights under this clause.
5. Without prejudice to the Doctor's other remedies at law the Doctor shall be entitled to cancel all or any part of any order of the Patient which remains unfulfilled and all amounts owing to the Doctor shall, whether or not due for payment, become immediately payable if:
  1. any money payable to the Doctor becomes overdue, or in the Doctor's opinion the Patient will be unable to make a payment when it falls due;
  2. the Patient becomes insolvent, convenes a meeting with its creditors or proposes or enters into an arrangement with creditors, or makes an assignment for the benefit of its creditors; or
  3. a receiver, manager, liquidator (provisional or otherwise) or similar person is appointed in respect of the Patient or any asset of the Patient.
Privacy Act 1993
1. The Patient authorises the Doctor or the Doctor's agent to:
  1. access, collect, retain and use any information about the Patient;
    1. (including any overdue fines balance information held by the Ministry of Justice) for the purpose of assessing the Patient's creditworthiness; or
    2. for the purpose of marketing products and services to the Patient.
  2. disclose information about the Patient, whether collected by the Doctor from the Patient directly or obtained by the Doctor from any other source, to any other credit provider or any credit reporting agency for the purposes of providing or obtaining a credit reference, debt collection or notifying a default by the Patient.
2. Where the Patient is an individual the authorities under clause 3 are authorities or consents for the purposes of the Privacy Act 1993.
3. The Patient shall have the right to request the Doctor for a copy of the information about the Patient retained by the Doctor and the right to request the Doctor to correct any incorrect information about the Patient held by the Doctor.

I certify that the above information is true and correct. I authorise the use of my personal information as detailed in the Privacy Act clause. I have read and understand the PAYMENT TERMS AND CONDITIONS (above) of Medicross Taranaki Limited T/A Medicross Taranaki which form part of, and are intended to be read in conjunction with this Patient Information Form and agree to be bound by these conditions.

GUARANTEE

If I execute this agreement as the person responsible for payment on behalf of the Patient I guarantee the due and punctual payment of all monies payable under this agreement. This Guarantee and Indemnity shall constitute an unconditional and continuing guarantee and indemnity and accordingly shall be irrevocable and remain in full force and effect until the whole of moneys owing to the Doctor by the Patient and all obligations herein have been fully paid satisfied and performed.