Agreement by Patient
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 R500 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.
I hereby declare that the information above is true and correct. I have read the agreement and agree to the terms.