PATIENT INFORMATION

The personal information provided by patients is protected under the Protection of Personal Information Act (POPIA). This information is collected solely for the purposes of our practice and will be handled with the utmost confidentiality. We assure you that your personal data will not be shared with any third parties without your explicit consent. If you have any questions or concerns regarding our privacy practices, please feel free to reach out to us.

NAME OF PATIENT*

DATE OF BIRTH OF PATIENT*

PATIENT CONTACT NUMBER*

PATIENT EMAIL *

IS THE PATIENT ON MEDICAL AID?*

PRIVATE

MEDICAL AID

FULL NAME OF MAIN MEMBER / PERSON RESPONSIBLE FOR ACCOUNT

MAIN MEMBER DOB*

ID *

ADDRESS*

MEDICAL AID PLAN*

MEDICAL AID MEMBER NUMBER*

ADDRESS*

NEXT OF KIN*

PAYMENT RESPONSIBILITY: This practice/doctor is not contracted with any medical aid provider. Services are not covered directly by your medical aid. You are responsible for settling your account in full at the time of service, regardless of medical aid coverage.*

I acknoledge and accept.

MEDICAL AID REIMBURSEMENT: All payments must be made upfront. Receipts will be provided for reimbursement submissions to your medical aid. If you are covered by medical aid, it is your responsibility to submit your invoice for reimbursement. Any outstanding amounts not covered by your medical aid remain your responsibility.

I acknowledge and accept.

RATES: Our rates follow the guidelines of the Health Professions Council of South Africa (HPCSA). A breakdown of fees will be provided at the time of consultation, with prior notice of any changes.*

I acknowledge and accept

LATE / NON PAYMENT: Failure to pay or settle upfront may result in the suspension or refusal of services, with overdue payments subject to collection procedures.*

I acknowledge and agee

I confirm that the patient information I provided is accurate and up-to-date to the best of my knowledge. I understand that I am responsible for my account and that I will be claiming the costs back from my medical aid myself.*

I AGREE