Patient Portal Consent Form

To subscribe to the Profile Patient Portal, fill out and sign the Consent Form after reading the terms. You can get the form from reception, or download it here.

Either present the form to reception, email it to reception@ratanui.co.nz, or upload it digitally below. Once we receive your completed and signed form, you will get an invoice for $20. You can pay at reception or via bank transfer to the following account:

Ratanui Medical Services
Bank Account
02-0152-0575655-000
Patient Name
Pack/File No — If known
Reference Invoice — IN****

When doing the bank transfer, please make sure you include your full name, patient/pack number, and invoice reference with the payment.

After payment is received, you will be invited to access the portal. Instructions for the Patient Portal are available here.

Digitally Upload the Patient Portal Consent Form

Name

First Name

Last Name

Date Of Birth

MM

DD

YYYY

Pack No

NHI

Phone

Email Address

Please include any children or dependants that you give consent to access

Required are name and DOB