Clinic #*
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Please type in your unique 5-digit clinic ID number that you were provided with when you made your appointment.

Family Name:*
Given Names:*
Date of Birth:*
Home Address:*
Post code*
Postal Address (if different):
Post code
Telephone home:*
Telephone work:
Usual family Doctor:
Referring Doctor:
Medical Insurer:

If your appointment relates to an ACC injury we require the following:

ACC claim number
Date of injury

If patient is a dependant child:

Name of parent:
How did you come to hear of Da Vinci Clinic, Mr Adam Bialostocki or Mr Brandon Adams
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Following your consultation, a letter is usually sent to your Doctor to keep him/her informed.
If for any reason you would prefer this letter NOT to be sent, please tick the box below.

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  • For some sensitive examinations, a Chaperone will be present.
  • Any unpaid accounts will incur late payment fees. If your account is sent to a debt collection agency, these collection costs will be added to the debt and will become the responsibility of the debtor.

Click here to read the terms & conditions for Da Vinci Clinci for your reference.

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Previous Surgery:
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If you have come for a Cosmetic Consultation, what aspect of your appearance would you like to discuss today?