Patient Form

Please note that we are a private practice and do not accept medical aids

Patient Email / Pasiënt epos:

Particulars of Patient / Pasiëntbesonderhede

Surname / Van:
Full Names / Volle Name:
Title / Titel:
Nick Name / Noem naam:
Date of Birth / Geboorte Datum:
Tel(H):
ID or Passport Number / ID of Paspoortnommer:
Tel(W):
Address / Adres:
Cell:
Occupation / Beroep:
Employer / Werkgewer:

A Relative that does not live at the above address /
'n Naasbestaande wat nie by bogenoemde adres woon nie

Surname / Van:
Name / Naam:
Tel:
Cell:
Relationship / Verwantskap:

Medical aid and Main Member details /
Mediese fondsen Hoof lid besonderhede

WE ARE A PRIVATE PRACTICE AND DO NOT ACCEPT MEDICAL AIDS: MEDICAL AID INFORMATION SUPPLIED WILL REFLECT ON YOUR ACCOUNT FOR CLAIMING PURPOSES

Surname / Van:
Full Names / Volle Name:
ID or Passport Number / ID of Paspoortnommer:
Marital Status / Huwelikstatus:
Medical Aid / Mediese Fonds:
Member No / Lid Nr:
Home Address / Woonadres:
Postal Address / Posadres:
Employer / Werkgewer:
Cell No / Sel:
Work Adress / Werks Adres:
Tel (H):
Tel (W):
Email / Epos:

How would you prefer to be contacted? / Hoe kan ons u kontak?
How did you get to know about us? / Hoe het u van ons te hore gekom?

Medical History / Mediese Geskiedenis

Does one of the following apply to your medical background? / Verwys enige van die volgende na u mediese toestand?
Pregnant / Verwagtend
Hepatitis
Reaction to local anaesthetic / Reaksie op verdowing
Rheumatic Fever / Rumatiekkoors
Bleeder / Bloeier
Heart Condition / Hart Kondisie
HIV/Aids / MIV/Vigs
Diabetic / Diabetes
Porphyria / Porferie
Epileptic fits / Epileptiese aanvalle
High/Low Blood Pressure / Bloeddruk (hoog of laag)
Allergies / Allergieë
Please state any allergies / Noem Allergieë
Please state any previous operations/Artificial replacements/heart operations or valve replacements
Medications / Huidige Medikasie

Agreement by Patient / Ooreenkoms deur Pasient

I agree and understand that the contract is entered into by me and the practice and NOT the medical aid. I understand that the payment of services rendered remains my responsibility and as this is a PRIVATE PRACTICE payment will be made immediately. I agree and undertake to cancel all appointments not less that 24(twenty four) hours prior to such, should I fail to cancel, I will remain liable for R300 per half hour of late cancellation. Appointments longer than one hour will require cancellation 48 (forty eight) hours before the scheduled appointment. All accounts are charged at private practice fees and remain my liability. I agree that should my account be handed over for collection, I should be liable for all attorney and own client fees, collection charges and all disbursements. I agree that the account and payment of account is subject tot the Prescribed Rate of Interest Act and that I remain for mora interest on accounts that have not been settled within 60 days. I agree to inspection of and negative listing of my credit information should my account remain outstanding. I choose the above address as my domicilium.

Ek verstaan dat die verantwoordelikheid vir betaling van dienste ontvang steeds op my rus en NIE die mediese fonds en aangesien hierdie 'n kontant praktyk is sal betaling onmiddelik geskied. Verder ondeneem ek om alle afsprakte te kanselleer waar nodig, nie minderas 24 (vier en twintig) uur voor sondanige afspraak. Afsprake van langer as 'n uur verlang kasellasie 48 (agt en veertig) uur voor die tyd. Indien ek versuim bly ek verantwoordelik vir R300 per halfuur van gemisde afspraak. Ek verstaan dat alle eise teen privaat fooie gehef word en steeds my verantwoordelikheid bly. Ek onderneem om, indien my rekening oorhandig word vir invordering, alle prokureer en eie kliënt fooie, invorderings kostes en uitgawes te vereffen. Ek verstaan dat my rekening onderhewig is aan die Wet op Voorgeskrewe Rentekoerse en dat ek 'n aaspreeklik is vir mora rente op al my rekeninge welke nie binne 60 dae vereffen is nie. Ek stem toe tot navraag op en negatiewe lysting van my krediet inligting sou die rekening uitstaande bly. Ek kies bogenoemde adres as my domicilium.

I hereby declare that the information above is true and correct. I have read the agreement and agree to the terms.
Ek verklaar dat die bogenoemde inligting waar en korrek is. Ek het die ooreenkoms gelees en aanvaar die ooreenkoms

Signature
Date: