Patient Info Sheet

First Name *

Surname *

Your I.D. Number *

Date of birth *

Age *

Home Address: *

Home Telephone *

Work Telephone *

Cell Number *

Email *

Occupation *

Employer *

Referring Doctor or G.P. *

Medical Aid *

Medical Aid Plan *

Medical Aid No *

Main Member *

Member ID No *

I acknowledge that I have been informed that this practice charges at Private Rates and not the rates that the Department of Health has unilaterally determined for doctors, which are known as the Reference Price List (RPL). Please note you are responsible for the account and not the Medical Aid. Please settle then claim back. I confirm that I am aware that the RPL values for services are available from the Dept. of Health (Tel no:012 312 0000) and the Health Professions Council of S.A. (Tel no:012 338 9300) and www.doh.gov.za. I accept that I am fully responsible for payment for services rendered and should I not pay timeously, understand that I will be liable for debt recovery costs on an attorney and own client scale and interest will be added at 18% per annum. We do not routinely remind patients about their follow-up appointments. If you would like a reminder, please let the receptionist know. Appointments not canceled within 24 hours will be charged for in full. I have read, noted, understand, and accept these terms.

I agree to the terms and confirm that the information given in this form is true, complete and accurate.